STATE OF MAINE DISTRICT COURT Location Docket No.
Plaintiff v. AFFIDAVIT FOR CONFIDENTIAL ADDRESS
(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 confidential. The plaintiff's address is:
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 made oath to the truth of the statements in the above affidavit, before me,
and signed
Date: Clerk / Notary Public / Attorney at Law
PA-015, Rev. 09/01