NDLSHC [1] Stip DWC Form 5 Inst/May 2017 DIVORCE WITH AN AGREEMENT 226 WITH CHILDREN INSTRUCTIONS FOR FORM 5: CONFIDENTIAL INFORMATION FORM (Form 5: Confidential Information Form is part of the Divorce With an Agreement 226 With Children packet of forms. Review the instructions for the packet of forms before completing the Confidential Information Form.) ND Legal Self Help Center Staff and Court employees cannot help you fill out forms. If you are unsure how to proceed, you should consult a lawyer. There is no guarantee that all judges and courts will accept forms available through the ND Legal Self Help Center. Use at your own risk. Do not include this instruction sheet when you serve or file the completed form. THE PLAINTIFF AND DEFENDANT WORK TOGETHER TO COMPLETE FORM. Form 5: Confidential Information Form gives the court the confidential information that cannot be included in any other forms filed in the case. This form remains confidential and is not a public record. Top of form (Caption): Fill in the caption exactly as you filled in the caption on Form 1: Summons. Plaintiff, Defendant and Minor Child(ren) Information: Full Information Column Fill in the full, legal names, birth dates and social security numbers of the Plaintiff, Defendant and each minor child listed in Paragraph 5 of Form 2: Complaint. If a minor child does not have a social security number, type or write 223N/A.224 If you have more than three minor children together, attach a sheet that lists the information for each additional child. Redacted Information Column Fill in the information as it appears in the documents that will be seen by the public. Financial Account Information: Review the Settlement Agreement (Form 3) for all financial account numbers. Only the last 4 digits of the financial account numbers should be listed on the Settlement Agreement. American LegalNet, Inc. www.FormsWorkFlow.com NDLSHC [2] Stip DWC Form 5 Inst/May 2017 Full Information Column Fill in the full information for each financial account listed in the Settlement Agreement. Redacted Information Column List the last 4 digits of the financial account number next to the full information for each financial account. Date and Signature: Sign and date the completed form. Do not include this instruction sheet when you serve or file the completed form. American LegalNet, Inc. www.FormsWorkFlow.com NDLSHC 1 Stip DWC Form 5/ 2017 STATE OF NORTH DAKOTA IN DISTRICT COURT COUNTY OF JUDICIAL DISTRICT ) ) (Plaintiff) ) Case No. PLAINTIFF, ) ) Vs ) CONFIDENTIAL INFORMATION FORM ) (Defendant) ) DEFENDANT. ) FULL INFORMATION REDACTED INFORMATION PLAINTIFF: Name: Date of Birth: Year of Birth: Social Security #: XXX-XX- DEFENDANT: Name: Date of Birth: Year of Birth: Social Security #: XXX-XX- MINOR CHILD: Name: Initials: Date of Birth: Year of Birth: Social Security #: XXX-XX- MINOR CHILD: Name: Initials: Date of Birth: Year of Birth: Social Security #: XXX-XX- MINOR CHILD: Name: Initials: Date of Birth: Year of Birth: Social Security #: XXX-XX- American LegalNet, Inc. www.FormsWorkFlow.com NDLSHC 2 Stip DWC Form 5/ 2017 FULL INFORMATION REDACTED INFORMATION FINANCIAL ACCOUNT NUMBERS: Name of Account: Account Number: Last 4 Digits: Name of Account: Account Number: Last 4 Digits: Name of Account: Account Number: Last 4 Digits: Name of Account: Account Number: Last 4 Digits: Name of Account: Account Number: Last 4 Digits: Dated this day of , 20 , Plaintiff (Signature of Plaintiff) , Defendant (Signature of Defendant) American LegalNet, Inc. www.FormsWorkFlow.com