JV-024 (Rev. 04/20/2013)
AFFIDAVIT OF
PUBLIC ASSISTANCE
DOCKET NUMBER
Trial Court of Massachusetts
Juvenile Court Department
DIVISION
1. I, , 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 are:
3. a. I am receiving public assistance. Yes No
b. I have received public assistance in the past. Yes 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 Children and Families
Division of Medical Assistance (Medicaid)
Other (Please specify):
4. a. The child(ren) listed above is/are receiving public assistance. Yes No
b. The child(ren) listed above received public assistance in the past. Yes No
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 Children and Families
Division of Medical Assistance (Medicaid)
Other (Please specify):
This affidavit must be personally signed by the plaintiff listed in Section 1. If the 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 day of 20 under the penality of perjury.
Signature: Printed Name:
Signature: Printed Name:
(Plaintiff)
(Attorney)
