STATE OF MAINE
DISTRICT COURT Location _____________________ Docket No. ___________________
Plaintiff v.
AFFIDAVIT FOR CONFIDENTIAL ADDRESS 19-A M.R.S. § 1653(6)(D) Defendant
For the protection of the address confidential. The
plaintiff’s
plaintiff
defendant this request is made to keep his / her
defendant’s address is:
The undersigned plaintiff defendant 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: FM-057, Rev. 04/14
Clerk / Notary Public / Attorney at Law Page 1 of 1