Form OCAJ-1 TRC IV "Affidavit Disclosing Care or Custody Proceeding Pursuant to Trial Court Rule Iv" - Massachusetts

What Is Form OCAJ-1 TRC IV?

This is a legal form that was released by the Trial Court of Massachusetts - a government authority operating within Massachusetts. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on July 1, 1995;
  • The latest edition provided by the Trial Court of Massachusetts;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form OCAJ-1 TRC IV by clicking the link below or browse more documents and templates provided by the Trial Court of Massachusetts.

ADVERTISEMENT
ADVERTISEMENT

Download Form OCAJ-1 TRC IV "Affidavit Disclosing Care or Custody Proceeding Pursuant to Trial Court Rule Iv" - Massachusetts

Download PDF

Fill PDF online

Rate (4.3 / 5) 7 votes
DOCKET NUMBER
TRIAL COURT OF MASSACHUSETTS
AFFIDAVIT DISCLOSING CARE
OR CUSTODY PROCEEDING
Pursuant to Trial Court Rule IV
Name of Case
BMC
District Court
Juvenile Court
Prob & Family Court
Superior Court
Division
Division
Division
Division
Division
I,
hereby declare, to the best of my knowledge, information, and
Section
belief that all information on this form is true and complete:
1
The name(s) of the child(ren) whose care or custody is at issue in this case are:
Section
2
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.
Section
The party filing this affidavit may request certain addresses to be kept confidential if the address is a shelter for battered
3
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
The address(es) of the above-named child(ren) whose care and custody is at issue in this case is/are:
4
Address(es):
Address(es) During the Last 2 Years, if Different
CHILD A
CHILD B
CHILD C
Section
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
Section
6
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.
Section
The following is a list of all pending or concluded proceedings I have participated in or know of involving the care or custody of
7
the above-named child(ren):
[W]itness [P]arty
Letter of Child
Court
Docket No.
Status
[O]ther
[N]one
CHILD
[ ]
CHILD
[ ]
CHILD
[ ]
Section
The names and addresses of parties to care or custody proceedings involving any of the above-named child(ren) or those
8
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
If the box at the right is checked, this affidavit discloses the adoption of one or more of the above-named
Section
9
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
ADDRESS OF ATTORNEY OF RECORD FOR JUVENILE/INCOMPETENT
THE PARTY FILING THIS AFFIDAVIT MUST FURNISH A COPY OF IT TO ALL OTHER PARTIES TO THIS ACTION.
OCAJ-1 TRC IV (07/95)
DOCKET NUMBER
TRIAL COURT OF MASSACHUSETTS
AFFIDAVIT DISCLOSING CARE
OR CUSTODY PROCEEDING
Pursuant to Trial Court Rule IV
Name of Case
BMC
District Court
Juvenile Court
Prob & Family Court
Superior Court
Division
Division
Division
Division
Division
I,
hereby declare, to the best of my knowledge, information, and
Section
belief that all information on this form is true and complete:
1
The name(s) of the child(ren) whose care or custody is at issue in this case are:
Section
2
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.
Section
The party filing this affidavit may request certain addresses to be kept confidential if the address is a shelter for battered
3
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
The address(es) of the above-named child(ren) whose care and custody is at issue in this case is/are:
4
Address(es):
Address(es) During the Last 2 Years, if Different
CHILD A
CHILD B
CHILD C
Section
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
Section
6
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.
Section
The following is a list of all pending or concluded proceedings I have participated in or know of involving the care or custody of
7
the above-named child(ren):
[W]itness [P]arty
Letter of Child
Court
Docket No.
Status
[O]ther
[N]one
CHILD
[ ]
CHILD
[ ]
CHILD
[ ]
Section
The names and addresses of parties to care or custody proceedings involving any of the above-named child(ren) or those
8
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
If the box at the right is checked, this affidavit discloses the adoption of one or more of the above-named
Section
9
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
ADDRESS OF ATTORNEY OF RECORD FOR JUVENILE/INCOMPETENT
THE PARTY FILING THIS AFFIDAVIT MUST FURNISH A COPY OF IT TO ALL OTHER PARTIES TO THIS ACTION.
OCAJ-1 TRC IV (07/95)
A
A
The party filing this affidavit may request certain address(es) to be kept confidential if the address is a shelter for battered persons
D
D
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
D
D
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
R
R
E
E
believe the above provision applies to you, complete sections 10 and 11 below, and DO NOT complete sections 4 and 5.
S
S
S
S
E
E
The address(es) of the child(ren) listed in section 2 whose care or custody is at issue in this case
S
S
are:
T
T
O
O
Child(ren)
Address(es)
Address(es) During Last 2 Years,
B
B
If Different
E
E
Child A.
K
K
Street Address
Street Address
E
E
P
P
T
T
City, State, Zip Code
City, State, Zip Code
Section
C
C
10
Child B.
O
O
N
N
Street Address
Street Address
F
F
I
I
City, State, Zip Code
City, State, Zip Code
D
D
E
E
Child C.
N
N
Street Address
Street Address
T
T
I
I
A
A
City, State, Zip Code
City, State, Zip Code
L
L
Section
My address is:
11
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.
1.
Attorney(s) for child(ren). (Please specify if each child is represented by a different attorney.)
2.
GAL(s)/Investigator(s) (Please indicate if a GALhas been appointed to represent a specific child.)
Section
3.
12
Attorney(s) for mother
4.
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.
List the names of all child(ren) involved in this care or custody proceeding. All future references to the child(ren) listed in
Section 2
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
Section 3
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.
Sections 4 & 5
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.
Section 6
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
Section 7
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.
Section 8
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.
Section 9
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.
Section 12
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
Signature
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.
Page of 3