Free Public Assistance Affidavit - Massachusetts

Commonwealth of Massachusetts The Trial Court Probate and Family Court Department
Division Case Name: Docket No:

Public Assistance Affidavit
1. I, petitioner/plaintiff, hereby declare that I have made inquiry

and, to the best of my knowledge, information and belief all of the information on this form is true, accurate and complete. 2. The name(s) and address(es) of the child(ren) who is/are the subject of this complaint or petition: Name (s) Address

3a. I am receiving public assistance. b. I have received public assistance in the past.

Yes Yes

No No

If the response is yes to either 3a or 3b, please specify the type of public assistance received: Department of Transitional Assistance (Public Welfare) Department of Social Services Department of Medical Assistance (Medicaid) Other (Please Specify) 4a. The child(ren) listed is/are receiving public assistance. Yes No Yes No

b. The child(ren) listed has/have received public assistance in the past.

If the response is yes to either 4a or 4b, please specify the type of public assistance received: Department of Transitional Assistance (Public Welfare) Department of Social Services Department of Medical Assistance (Medicaid) Other (Please Specify) This affidavit must be personnally signed by the petitioner/plaintiff listed in Section 1. If the petitioner/plaintiff is under the age of 18 years and is represented by an attorney, the attorney must also sign this affidavit. A revised affidavit must be filed with the Court if new information is discovered subsequent to this filing. Signed this Signature: Attorney: day of Printed Name: Printed Name: 20

c.g.f.