Confidential Information Form (INFO)

Confidential Information Form (INFO)
County:
Cause Number:
Do not file in a
Court Clerk: This is a Restricted Access Document
public access file.
Divorce/Separation/Invalidity/Nonparental Custody/Paternity/Modifications
Sexual Assault
Other
Domestic Violence
Antiharassment
Information Change (Check if you are updating information)
A restraining order or protection order is in effect protecting the petitioner the respondent
the children.
The health, safety, or liberty of a party or child would be jeopardized by disclosure of address
information because:
The following information about the parties is required in all cases:
(Use the Addendum To Confidential Information Form to list additional parties or children)
Petitioner Information
Type or Print Only
Name (Last, First, Middle)
Race
Sex
Respondent Information
Name (Last, First, Middle)
Birthdate
Race
Sex
Birthdate
Driver’s Lic. or Identicard (# and State)
Driver’s Lic. or Identicard (# and State), (or, if
unavailable, residential address)
Mailing Address (P.O. Box/Street, City, State, Zip)
Mailing Address (P.O. Box/Street, City, State, Zip)
Relationship to Child(ren)
Relationship to Child(ren)
The following information is required if there are children involved in the proceeding. (Soc. Sec.
No. is not required for petitions in protection order cases (Domestic Violence/Antiharassment/Sexual Assault).)
1) Child's Name (Last, First, Middle)
Child's Race/Sex/Birthdate
Child's Soc. Sec. No. (If required)
Child's Present Address or Whereabouts
WPF DRPSCU 09.0200 Confidential Information Form (INFO) (07/2011) RCW 26.23.050- Page 1 of 2
2) Child's Name (Last, First, Middle)
Child's Race/Sex/Birthdate
Child's Soc. Sec. No. (If required)
Child's Present Address or Whereabouts
List the names and present addresses of the persons with whom the child(ren) lived during the last five
years:
List the names and present addresses of any person besides you and the respondent who has physical
custody of, or claims rights of custody or visitation with, the child(ren):
Except for petitions in protection order cases (Domestic Violence/Antiharassment/
Sexual Assault), the following information is required:
Petitioner's Information
Respondent's Information
Soc. Sec. No.:
Soc. Sec. No.:
Residential Address (Street, City, State, Zip)
Residential Address (Street, City, State, Zip)
E-mail Address:
Telephone No.: (
E-mail Address:
Telephone No.: (
)
Employer:
Employer:
Empl. Address:
Empl. Address:
)
Empl. Phone No.: (
)
Empl. Phone No.: (
)
For Nonparental Custody Petitions only, list other Adults in Petitioner(s) household (Name/DOB):
Additional information:
Addendum(s) To Confidential Information Form attached. List other parties or children in Addendum(s).
I certify under penalty of perjury under the laws of the state of Washington that the above information is
true and accurate concerning myself and is accurate to the best of my knowledge as to the other party, or
is unavailable. The information is unavailable because
.
Signed on __________________ (Date) at ____________________________________ (City and State).
Petitioner/Respondent
WPF DRPSCU 09.0200 Confidential Information Form (INFO) (07/2011) RCW 26.23.050- Page 2 of 2