Petitioner's Motion to seal address and telePhone nuMber in the district court of the fifth circuit li hu`e division state of hawai`i Petitioner Form #5DC01 Reserved for Court Use Civil No. Respondent SS Filing Party/Attorney Name, Attorney Number, Firm Name (if applicable), Address, Telephone and Fax Numbers (Petitioner - leave this box blank) PETITIONER'S MOTION TO SEAL ADDRESS AND TELEPHONE NUMBER DECLARATION I DECLARE UNDER PENALTY OF PERJURY THAT THE FOLLOWING IS TRUE AND CORRECT. l. 2. I am the Petitioner. I am requesting that the Court seal my address and/or telephone number because (state facts why you are making the request): Signature of Petitioner: Date: Reserved for Court Use Print/Type Name(s): COURT ORDER This motion is: q GRANTED q DENIED Date: Judge: In accordance with the Americans with Disabilities Act , and other applicable State and Federal laws, if you require an accommodation for your disability when working with a court program, service, or activity please contact the Deputy Chief Court Administrator's Office at PHONE NO. (808) 482-2347, FAX (808) 482-2509, OR TTY (808) 482-2533 at least (10) working days in advance of your hearing, or appointment date. Reprographics (01/10) American LegalNet, Inc. www.FormsWorkFlow.com 5D-P-167