Person Filing: Address (if not protected): City, State, Zip Code: Telephone: Email Address: ATLAS Number: Lawyer222s Bar Number: Representing Self, without a Lawyer or Attorney for Petitioner OR Respondent SUPERIOR COURT OF ARIZONA IN MARICOPA COUNTY Case No. Petitioner / Party A ATLAS No. Respondent / Party B FAMILY DEPARTMENT /SENSITIVE DATA COVERSHEET WITHOUT CHILDREN (CONFIDENTIAL RECORD) Fill out. File with Clerk of Superior Court. Social Security Numbers should appear on this form only and should be omitted from other court forms. Access Confidential pursuant to ARFLP 43.1(f). A. Personal Information: Petitioner / Party A Respondent / Party B Name Gender Male or Female Male or Female Date of Birth (Month/Day/Year) Social Security Number WARNING: DO NOT INCLUDE MAILING ADDRESS ON THIS FORM IF REQUESTING ADDRESS PROTECTION Mailing Address City, State, Zip Code Contact Phone Email Address Current Employer Name Employer Address Employer City, State, Zip Code Employer Telephone Number Employer Fax Number B. Type of Case being filed - Check only one category. *Check only if no other category applies Interpreter Needed: Yes No Dissolution (Divorce) If yes, what language(s)? Legal Separation Annulment Order of Protection Other* FOR CLERK222S USE ONLY DO NOT COPY THIS DOCUMENT. DO NOT SERVE THIS DOCUMENT TO THE OTHER PARTY. 251 Superior Court of Arizona in Maricopa County DRSDS10fAnn 010119 ALL RIGHTS RESERVED Page 1 of 1 American LegalNet, Inc. www.FormsWorkFlow.com