Free DRL §§76-h (5), 254; FCA §§ 154-b; 818; 1015 FAMILY COURT OF THE STATE OF NE... - New York

DRL §§76-h (5), 254; FCA §§ 154-b; 818; 1015 FAMILY COURT OF THE STATE OF NEW YORK COUNTY OF _______________________________ ............................................................................... Petitioner, -againstRespondent .............................................................................. STATE OF NEW YORK ) )ss.: COUNTY OF ) 1. I, [specify name]: proceeding.

General Form 21 Address Confidentiality Affidavit (9/2006)

Docket No. ADDRESS CONFIDENTIALITY AFFIDAVIT

, am the Q Petitioner Q Respondent in the above entitled

2. I am requesting address confidentiality because [check applicable boxes] Q Disclosure of my address or other identifying information would pose an unreasonable risk to my health or safety or my child(ren)'s health or safety. Q I am in a residential program for victims of domestic violence or a shelter provided for parents accompanying abused or neglected children, or a shelter for homeless persons. Q I have an address confidentiality order from [specify court or state agency and date]: 3. I designate the following person as the agent for service of process and all papers in this case [specify, Clerk of Court, attorney or other person and address]:1 4. I agree to inform the person named above as the agent for service of process of any change in my address. _________________________________ Signature Sworn to before me this day of , _________________________________ Print or type name _____________________________ Notary Public (Deputy) Clerk of the Court _________________________________ Signature of Attorney, if any ________________________________ Attorney's Name (Print or Type) ________________________________ ________________________________ Attorney's Address and Telephone Number

Any person over the age of 18, who is not a party to the proceeding, or the Clerk of the Court may be designated as the agent for service of process and papers.

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