Address Confidentiality Affidavit printable pdf download

Address Confidentiality Affidavit

DRL §§76-h (5), 254; Exec. L. §108;

General Form 21

FCA §§ 154-b; 818; 1015

Address Confidentiality Affidavit

(9/2012)

FAMILY COURT OF THE STATE OF NEW YORK

COUNTY OF _______________________________

...............................................................................

Petitioner,

Docket No.

ADDRESS CONFIDENTIALITY

-against-

AFFIDAVIT

Respondent

..............................................................................

STATE OF NEW YORK

)

)ss.:

COUNTY OF

)

1. I, [specify name]:

, am the

Petitioner

Respondent in the above-named

proceeding.

2. I am requesting address confidentiality because [check applicable boxes] :

Disclosure of my address or other identifying information would pose an unreasonable

risk to my health or safety or my child(ren)’s health or safety.

I am in a residential program for victims of domestic violence or a shelter provided for

parents accompanying abused or neglected children, or a shelter for homeless persons.

I have an address confidentiality order from [specify court or state agency and date]:

I have been approved for participation in the Address Confidentiality Program of the

NYS Department of State. My participation expires on [specify date]:

3. [REQUIRED except for participants in the NYS Department of State Address Confidentiality

program]: I designate the following person as the agent for service of process and all papers in this case

[specify, Clerk of Court, attorney or other person and address]:

4. I agree to inform the person named above as the agent for service of process or, if applicable,

the NYS Department of State promptly of any change in my address.

_________________________________

Signature

Sworn to before me this

_________________________________

Print or type name

_________________________________

_____________________________

Signature of Attorney, if any

Notary Public

________________________________

(Deputy) Clerk of the Court

Attorney’s Name (Print or Type)

________________________________

Attorney’s Address and Telephone Number

Any person over the age of 18, who is not a party to the proceeding, or the Clerk of the Court

may be designated as the agent for service of process and papers.

Address Confidentiality Affidavit

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