AFFIDAVIT DISCLOSING CARE  
OR CUSTODY PROCEEDING 
Pursuant to Trial Court Rule IV   
  
BMC 
  
 
Division 

District Court 
  
 
Division 

TRIAL COURT OF MASSACHUSETTS 
  
 Name of Case

 

DOCKET NUMBER

 

Juvenile Court 
  
 
Division 

Prob & Family Court 
  
 
Division 

Superior Court 
  
 
Division 

Section 
1 

Section 
2 

Section 
3 

 

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)

Use only the letter appearing in front of the child's name above when referring to the 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  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.  

 

Section 
4

The address(es) of the above-named child(ren) whose care and custody is at issue in this case is/are: 
Address(es): 
CHILD A 
 

           Address(es) During the Last 2 Years, if Different 

 

 

 

 

 

 
CHILD B 

CHILD C

 

Section 
5 

My address is:

 

 

 

Section 
6 

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 state or country.

 

 

 

 

Certified copies of any pleadings or determinations in care a 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 above-named child(ren):                                                                                                                             [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 those 
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 

            
            
          

 
 
 

 
 
 

 
 
 

 
 
 

 
 
 

 
 
 

 
 
 

 
 
 

 
 
 

 

 

 

 

     

     

     

     

Section 
7

Section 
8 
 

Section 
9

If the box at the right is checked, this affidavit discloses the adoption of one or more of the above-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. 

 

 

 

 X           

___________________________________________________
SIGNATURE OF PARTY OR ATTORNEY OF RECORD FOR JUVENILE/INCOMPETENT

 

PRINTED NAME OF PERSON SIGNING

  
 THE PARTY FILING THIS AFFIDAVIT MUST FURNISH A COPY OF IT TO ALL OTHER PARTIES TO THIS ACTION.

ADDRESS OF ATTORNEY OF RECORD FOR JUVENILE/INCOMPETENT

  

 

OCAJ-1 TRC IV (07/95)

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The party filing this affidavit may request certain address(es) 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 checked the box in section 3 indicating that you 
believe the above provision applies to you, complete sections 10 and 11 below, and DO NOT complete sections 4 and 5.  

The address(es) of the child(ren) listed in section 2 whose care or custody is at issue in this case 
are: 

Child(ren) 
 

 

Child A. 

 
 

 

   Address(es) 
 
 
 

 
 

 
 

Address(es) During Last 2 Years, 
                    If Different 

 

Street Address

Street Address

   

   

   

City, State, Zip Code

City, State, Zip Code

Street Address

Street Address

City, State, Zip Code

City, State, Zip Code

Street Address

Street Address

City, State, Zip Code

City, State, Zip Code

   

   

   

Section 
10

Child B. 

  

  

Child C.

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Section 
11 

My address is:

 

Street Address, City, State, Zip Code

LIST OF ATTORNEYS AND GUARDIANS AD LITEM/INVESTIGATORS 

Please list the names of all attorneys and guardians ad litem involved in the pending  
proceedings listed in section 7. 

Attorney(s) for child(ren).  (Please specify if each child is represented by a different attorney.)

GAL(s)/Investigator(s) (Please indicate if a GALhas been appointed to represent a specific child.)

1.  

  

2. 

  

3. 

4. 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Section 
12 

Attorney(s) for mother

Attorney(s) for father

(Fill Out Below If Applicable) 

 

     I,                                                                                                                             , attorney for 
D.C.F. or its agent have ascertained from the above checked off attorney(s) and guardian(s) ad 
litem/investigators a willingness to accept an appointment from the court to represent the same 
party should the court elect to make such appointment. 
 

(Signature)

READ BEFORE COMPLETING THE 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 of 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 submitted upon the filing of  an application for a Child Requiring Assistance (CRA) pursuant to G.L. c. 119. 
    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 of 
this affidavit. 
F.  WHAT MUST BE FILED AS PART OF THIS AFFIDAVIT?   
   Certified copies of each pleading and of any determination entered in a foreign country or in a state other than Massachusetts must be 
filed with this affidavit unless these documents are on file with the court in this case, or an extension has been granted by the court for filing 
these documents. 
INSTRUCTIONS FOR COMPLETING AFFIDAVIT  
   When completing this affidavit if additional space is needed for any of the sections, attach a separate sheet which includes  your name 
(printed), the docket number and the sections to which you are referring.  You must also sign and date the sheet. 
   The party filing this affidavit must complete the section entitled "Name of Case" and indicate the Court Department and Division in which 
the case is being brought.  The docket number should also be listed, if known. 

DO NOT COMPLETE SECTIONS 2, 3, 4, 8 AND 10 IF THIS AFFIDAVIT IS BEING FILED WITH A PETITION FOR ADOPTION.   
  Section 1 
  

You  must  print  your  first  and  last  name.    If  this  affidavit  is  filed  by  an  attorney  on  behalf  of  an  incompetent  person  or  a 
juvenile, the name of the party on which behalf this affidavit is being completed must be listed. 

Section 2 
  
  

Section 3 
  

Sections 4 & 5 
  
  
Section 6 

Section 7 
  
  
  
  
  
  

Section 8 
  
  

Section 9 
  
  

  
Section 12 

Signature

List the names of all child(ren) involved in this care or custody proceeding.  All future references to the child(ren) listed in 
this  section  should  be  with  the  letter  in  front  of  the  child's  name  (e.g.  If  John  Smith  is  listed  next  to  the  letter  A,  all 
references to John Smith will be as Child A). 

Check the box if this section applies to you.  If this box is checked, do not complete Sections 4 and 5.  You must complete 
Sections 10 and 11 on the reverse side of page 1. 

List the present and all prior addresses during the last two years of the above-named child(ren) and your present address. 
If legal custody of a child has been awarded to a social service agency, list the name and address of the agency with legal 
custody. 

Check the appropriate box. 

List all pending or concluded proceedings which you have participated in or know of involving the care or custody of the 
child(ren) named in this affidavit.  Indicate the letter of the child; the court in which the case was heard, the docket number, 
the  person(s)  to  whom  custody  was  awarded,  and  the  date  of  the  award,  and  the  nature  of  your  participation  in  the 
proceeding  by  listing  "W"  for  witness,  "P"  for  party,  "O"  for  other  or  "N"  for  none.    If  specific  information  required  in  this 
section is not known, you or your attorney should contact the court where the case was heard to obtain such information . 
In the case of a petition for adoption, list all information except the person(s) to whom custody was awarded, the 
date of the award and the nature of your participation.  Under the heading "Status of Case", indicate type of case. 

List the name(s) and current residential address(es), if known, otherwise the last known address(es) of parties to care or 
custody  proceedings  or  persons  claiming  a  legal  right  to  the  above-named  child(ren)  during  the  last  two  years.    Do  not 
include yourself. 

Check this box if this affidavit discloses the adoption of a child and you are requesting the court to impound this affidavit.  If 
this provision is applicable, you should contact the Clerk-Magistrate or Register of Probate for assistance concerning the 
appropriate motion to be filed. 

Sections 10 & 11 
  
  

COMPLETE ONLY IF YOU CHECKED THE BOX IN SECTION 3. 
List the present and all prior addresses during the last two years of the child(ren) listed in Section 2 of this affidavit and 
your present address.  If legal custody of a child has been awarded to  a social service agency, list the name and address 
of the agency with legal custody. 

List the attorneys and guardians ad litem/investigators previously appointed in Section 7. 

The  party  listed  in  Section  1  must  date  and  sign  this  affidavit  except  for  an  incompetent  or  juvenile,  in  which  case  the 
attorney of record on behalf of the juvenile or incompetent party must date and sign this affidavit and print his/her name 
and address.  

THIS AFFIDAVIT MUST BE FILED WITH THE COURT AND A COPY FURNISHED BY THE PARTY FILING IT TO ALL OTHER PARTIES TO THIS ACTION.