Affidavit For Confidential Address {PA-015}

STATE OF MAINE DISTRICT COURT Location Docket No. Plaintiff v. AFFIDAVIT FOR CONFIDENTIAL ADDRESS/ TELEPHONE NUMBER (19-A M.R.S.A. § 4008) (5 M.R.S.A. § 4656) Defendant For the protection of the plaintiff, the plaintiff requests the court to keep his/her address and/or telephone number(s)confidential. The plaintiff's address is: The plaintiff's telephone number(s) are: The undersigned plaintiff states under oath that the health, safety or liberty of myself and/or my child(ren) would be jeopardized by disclosure of this information for the following reasons: Date: Signature Personally appeared the above named and signed and made oath to the truth of the statements in the above affidavit, before me, Date: Clerk / Notary Public / Attorney at Law PA-015, Rev. 11/08 American LegalNet, Inc. www.FormsWorkFlow.com