Free Page 2 - Affidavit Disclosing Care and Custody - Confidential Address Form - Massachusetts

ADDRESSES TO BE KEPT CONFIDENTIAL

A D D R E S S E S T O B E K E P T C O N F I D E N T I A L

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 children(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 6.
The address(es) of the child(ren) listed in section 2 whose care or custody is at issue in this case are: Address(es) During Last 2 Years, If Different Child(ren) Address(es)

Child A.
Street Address Section 10 City, State, Zip Code Street Address City, State, Zip Code

A D D R E S S E S T O B E K E P T C O N F I D E N T I A L

Child B.
Street Address Street Address

City, State, Zip Code

City, State, Zip Code

Child C.
Street Address Street Address

Section 11

My address is: 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. 1.
Attorney(s) for child(ren). (Please specify if each child is represented by a different attorney

Section 12

2.
GAL(s) Investigator(s) Pleaase indicate if a GAL has been appointed to represent a specific child.

3.
Attorney(s) for mother

4.
Attorney(s) for father

(Fill Out below if Applicable)

I, attorney for D.S.S. 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 an appointment.

(Signature) Affidavit Disclosing Care or Custody - Page 2 Confidential c.g.f.