Affidavit Disclosing Care Or Custody Proceeding Involving A Child {OCAJ-1 TRC IV}

AFFIDAVIT DISCLOSING CARE OR CUSTODY PROCEEDING Pursuant to Trial Court Rule IV BMC ________________ Division Section 1 Section 2 TRIAL COURT OF MASSACHUSETTS Name of Case _______________________ Juvenile Court ________________ Division Prob & Family Court ________________ Division DOCKET NUMBER District Court ________________ Division Superior Court ________________ Division I, _________________________________________________ hereby declare, to the best of my knowledge, information, and belief that all information on this form is true and complete: The name(s) of the child(ren) whose care or custody is at issue in this case are: A. ________________________ B. ___________________________ C. ____________________________ (LAST, FIRST) (LAST, FIRST) (LAST, FIRST) U se only the letter appearing in front of the child's nam e above when referring to the child in com pleting the rem aining sections. Section 3 The party filing this affidavit may request certain addresses to be kept confidential if the address is a shelter for battered persons and their dependent child(ren, or the party filing this affidavit believes that he/she or the child(ren) are in danger of physical or emotional abuse, or the party is filing an action under G.L. c. 209A. If you believe that this provision applies to you, check the box at right, complete sections 10 and 11 on the reverse side of this page and DO NOT complete sections 4 and 5 below. The address(es) of the above-name child(ren) whose care and custody is at issues in this case is/are: Address(es) Address\ CHILD A ____________________________________ ______________________________________________________ CHILD B ____________________________________ ______________________________________________________ CHILD C ____________________________________ ______________________________________________________ My address is: _______________________________________________________________________________________ I 9 have 9 have not participated in and I 9 know 9 do not know of other care or custody proceedings involving the above-names child(ren) in Massachusetts or in any state or country. Section 4 Section 5 Section 6 Certified copies of any pleadings or determinations in a care or custody proceeding outside of Massachusetts listed in sections 7 and 8 must be filed with this affidavit unless already filed with this court or an extension for filing these documents has been granted by this court. Section 7 The following is a list of all pending or concluded proceedings I have participated in or know if involving the care or custody of the above named child(dren): [W]itness [P]arty Letter of Child Court Docket no. Status [O]ther [N]one CHILD _____ __________________________ _____________ _____________________________ [ ] CHILD _____ __________________________ _____________ _____________________________ [ ] CHILD _____ __________________________ _____________ _____________________________ [ ] The names and addresses of parties to care or custody proceedings involving any of the above-named child(ren) or thise claiming a legal right to these child(ren) during the last two years (not including myself) are: Letter of Child Name of Party/Claimant Current (or last known) Address of Party/Claimant CHILD _____ _______________________________________ _____________________________________________ CHILD _____ _______________________________________ _____________________________________________ CHILD _____ _______________________________________ _____________________________________________ If the box at the right is checked, this affidavit discloses the adoption of one or more of the abovenamed child(ren) and I am requesting the court to impound this affidavit. See instructions. Section 8 Section 9 This affidavit must be personally signed by the party listed in section 1 above, unless he/she is under 18 years of age or has been adjudged incompetent in which case the attorney of record must sign. A revised affidavit must be filed with the court if new information is discovered subsequent to this filing. Signed this __________________________ day of ______________________________, 20_______ under the penalties of perjury. X ___________________________________________________ SIGNATURE OF PARTY OR ATTORNEY OF RECORD FOR JUVENILE/INCOMPETENT _____________________________________ PRINTED NAME OF PERSON SIGNING _____________________________________________________________________________________________________________________________________________________________________ ADDRESS OF ATTORNEY OR RECORD FOR JUVENILE/INCOMPETENT THE PARTY FILING THIS AFFIDAVIT MUST FURNISH A COPY OF IT TO ALL OTHER PARTIES TO THIS ACTION. O C AJ-1 TCR IV (07/95) American LegalNet, Inc. www.FormsWorkFlow.com READ BEFORE COMPLETING AFFIDAVIT A. WHAT IS AN "AFFIDAVIT DISCLOSING CARE OR CUSTODY PROCEEDING"? It is a document signed under the penalties of perjury which lists information required by Trial Court Rule IV concerning children involved in a care or custody proceeding. B. WHO MUST FILE THIS AFFIDAVIT? The party to a petition (including a modification petition) or complaint involving the care, custody, visitation, or change of name of a child pursuant to G.L. c. 119 (except delinquency actions under G.L. c. 201, G.L. c. 207, G.L. c. 208, G.L. c. 209, G.L. c. 209A, G.L. c. 209C, G.L. c. 210, or any other provision of law concerning the care or custody of a child must file this affidavit. This affidavit must be signed by the party unless the party is under 18 years of age or has been adjudged incompetent in which case the attorney or record must sign this affidavit on behalf of the juvenile or incompetent party. C. WHEN MUST THIS AFFIDAVIT BE FILED? The person filing the petition or complaint must file this affidavit at the time of filing and the other party must file this affidavit with the first pleading. This affidavit should be filed upon issuance of a CHINS petition pursuant to G.L. c. 119, not upon application for such a petition. This affidavit need not be filed if the petition or complaint is for support only. D. WHERE MUST THIS AFFIDAVIT BE FILED? The completed affidavit must be filed, in person or by mail, with the Clerk-Magistrate or Register of Probate in the court in which this action is being brought. E. WHEN MUST A REVISED AFFIDAVIT BE FILED? A revised affidavit must be filed with the Clerk-Magistrate or Register of Probate if new information is discovered subsequent to the filing