For Clerk’s Use Only Name of Person Filing: ______________________________________ Mailing Address: ____________(PROTECTED)______________ ATLAS Number (if applicable): ______________________________________ Attorney Bar Number (if applicable):__________________________________ Self Petitioner Respondent Representing: SUPERIOR COURT OF ARIZONA MOHAVE COUNTY Case Number: (Name of Petitioner) REQUEST FOR PROTECTED ADDRESS AND (Name of Respondent) I request the court to order that my address be protected from public disclosure, including disclosure to the opposing party(ies) in this case. I reasonably believe that physical or emotional harm may result to me or my minor child(ren) if my address is not protected from disclosure, for the following reasons: I have a valid Order of Protection in place issued by the following court: _____________________________________________________________________ OR Other reasons briefly described: ____________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ I have listed my address on a separate sheet of paper for court use. I understand that I have a continuing duty to provide the Clerk or the Court with a current and correct mailing address where I can be served with process until one of the following events stated in Rule 7(D), Arizona Rules of Family Law Procedure occurs, __________________________________ Date 6/12/2008 _______________________________________ Requester’s Signature Page 1 of 2 American LegalNet, Inc. www.FormsWorkflow.com PERSON WHOSE ADDRESS IS PROTECTED: Petitioner Respondent ADDRESS TO BE PROTECTED: Name: ___________________________________________________________________ Street: ___________________________________________________________________ City: ___________________________________________________________________ State, Zip Code: ___________________________________________________________________ Telephone Number: ___________________________________________________________________ 6/12/2008 Page 2 of 2 American LegalNet, Inc. www.FormsWorkflow.com