JV-112 (Rev. 07/31/2013)
AFFIDAVIT IN SUPPORT OF PETITION FOR
INSPECTION OF RECORDS OF ADOPTION
G.L. c. 210, § 5C
DOCKET NUMBER
Trial Court of Massachusetts
Juvenile Court Department
NAME OF ADOPTED PERSON
DIVISION
ANSWER THE FOLLOWING QUESTIONS
1. The current name of the individual is:
2. My relationship to the individual adopted is:
3. I am applying to examine the adoption records for the following reasons:
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ANSWER NUMBERS 4 THROUGH 11, IF KNOWN BY YOU
4. The birth name of the individual is:
5. The birth date of the individual is:
6. The birth mother's name is/was:
7. The birth father's name is/was:
8. The adoptive mother's name is/was:
9. The adoptive father's name is/was:
10. The date and place of the adoption was:
11. The circumstances surrounding the adoption were:
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Signed under the pains and penalties of perjury this day of , 20 .
Petitioner's Signature:
Petitioner's Name (printed):
Petitioner's Address:
