IN THE DISTRICT SUPERIOR COURT FOR THE STATE OF ALASKA AT In the matter of: , ) ) ) ) ) ) ) ) A minor under 18 years of age. Date of birth: CASE NO. REQUEST TO KEEP IDENTIFYING INFORMATION CONFIDENTIAL IN TRIBAL COURT ICWA ORDER I ask the state court not to disclose identifying information about the following person or persons, and to keep the information confidential or sealed: child named above person awarded custody or visitation named I certify under penalty of perjury that the health, safety, or liberty of the person(s) above will be jeopardized by disclosing identifying information because: SIGNATURE AND NOTARY I certify under penalty of perjury that the information in this document is true. Print Name Signature (sign in front of the notary or court clerk) , Alaska on Subscribed and sworn to or affirmed before me at (SEAL) Clerk of Court, Notary Public or other person authorized to administer oaths. My commission expires CERTIFICATION (IF NO NOTARY AVAILABLE) I certify under penalty of perjury that the information in this document is true, and a notary or other official empowered to administer oaths is not available to administer an oath. Date Place (city or village) Signature Print Name 25 USC §§ 1901-1963; CINA Rules 24-25; AS 09.63.020 American LegalNet, Inc. www.FormsWorkFlow.com CN-625 (3/15)(cs) REQUEST TO KEEP IDENTIFYING INFORMATION CONFIDENTIAL