Use this template/form as an Affidavit Disclosing Care or Custody Proceedings Form in the State of Massachusetts
Text version of this Form
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AFFIDAVIT DISCLOSING CARE TRIAL COURT OF MASSACHUSETTS DOCKET NUMBER
OR CUSTODY PROCEEDINGS Name of
Pursuant to Trial Court Rule IV
Boston District Court Juvenile Court x Probate & Family Court Superior Court
Court Division Division Division Division
I, , hereby declare, to the best of
1 NAME OF PARTY (PRINT)
my knowledge, information and belief that all the 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:
Section A. B. C.
2 (LAST FIRST) (LAST FIRST) (LAST FIRST)
Use only the letter appearing in front of the child’s name above when referring to that child in completing the remaining sections.
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 the party who completed this affidavit believed this provision applied to him/her,
then the box at the right has been checked and sections 4 and 5 have not be completed.
The address(es) of the above-named child(ren) whose care or custodyis at issue in this case are:
Address(es) Address(es) During the Last 2 Years, If Different
Section CHILD A.
5 My address is:
I have have not participated in and I know do not know of other care or custody proceedings involving the above-named
child(ren) in Massachusetts or in any other state or country.
Certified copies of any pleadings or determination 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.
The following is a list of ALL pending or concluded proceedings I have participated in or know of involving the care or custody of the
Status of Case [P] arty
(Custody awarded to) [O] ther
Letter of Child Court Docket No.
Section (Date of award) [N] one
7 CHILD [ ]
CHILD [ ]
CHILD [ ]
The names and addresses of parties to care or custody proceedings involving any of the above-named child(ren) or those claiming a legal right to
these child(ren) during the last two years (including myself are:
Letter of Child Name of Party/Claimant Current (or last known) Address of Party/Claimant
Section If the box at the right is checked, this affidavit discloses the adoption of one or more of the above-
9 named child(ren) and I am requesting the court to impound this affidavit. See instructions.
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.
SIGNATURE OF PARTY OR ATTORNEY OF RECORD FOR INCOMPETENT/JUVENILE PRINTED NAME OF PERSON SIGNING
ADDRESS OF ATTORNEY OF RECORD FOR INCOMPETENT/JUVENILE
THE PARTY FILING THIS AFFIDAVIT MUST FURNISH A COPY OF IT TO ALL OTHER PARTIES TO THIS ACTION
OCAJ-1 TCR IV – AFFIDAVIT DISCLOSING CARE OR CUSTODY PROCEEDINGS C.G.F.