CONFIDENTIAL INFORMATION FORM THIS FORM IS CONFIDENTIAL 204 Pa. Code 247 213.81 www.pacourts.us/public-record (Party name as displayed in case caption) Docket/Case No. Vs. (Party name as displayed in case caption) Court This form is associated the pleading titled , dated , . Pursuant to the , the ConfidentialInformation Form a filing where confidential information is required bylaw, ordered by the court, orotherwise necessary to effect disposition of a matter. This form, and any , shall remainconfidential This nformation ertains to: Confidential Information: References in Filing: (full name of adult) OR This information pertains to a minor with the initials of and the full name of (full name of minor) and date of birth: (full name of adult) OR This information pert ains to a minor with the initials of and the full name of (full name of minor) and date of birth: Social Security Number (SSN): Financial Account Number (FAN): (DLN): State of Issuance: State Identification Number (SID): Social Security Number (SSN): Financial Account Number (FAN): (DLN): State of Issuance: State Identification Number (SID): Alternative Reference: SSN 1 Alternative Reference: FAN 1 Alternative Reference: DLN 1 Alternative Reference: SID 1 Alternative Reference: SSN 2 Alternative Reference: FAN 2 Alternative Reference: DLN 2 Alternative Reference: SID 2 American LegalNet, Inc. www.FormsWorkFlow.com CONFIDENTIAL INFORMATION FORM THIS FORM IS CONFIDENTIAL Additional page(s) attached. total pages are attached to this filing. I certify that this filing complies with the provisions of the that require filing confidential anddocuments differently than non-confidential information and documents. Signature of Attorney or Address: NOTE: Parties and attorney of record in a case will have access to this onfidential nformationorm. Confidentiality of this information must be maintained. Date American LegalNet, Inc. www.FormsWorkFlow.com CONFIDENTIAL INFORMATION FORM THIS FORM IS CONFIDENTIAL Additional page (if necessary) This nformation ertains to: Confidential Information: References in Filing: (full name of adult) OR This information pertains to a minor with the initials of and the full name of (full name of minor) and date of birth: (full name of adult) OR This information pert ains to a minor with the initials of and the full name of (full name of minor) and date of birth: Social Security Number (SSN): Financial Account Number (FAN): (DLN): State of Issuance: State Identification Number (SID): Social Security Number (SSN): Financial Account Number (FAN): (DLN): State of Issuance: State Identification Number (SID): Alternative Reference: SSN Alternative Reference: FAN Alternative Reference: DLN Alternative Reference: SID Alternative Reference: SSN Alternative Reference: FAN Alternative Reference: DLN Alternative Reference: SID (full name of adult) OR This information pertains to a minor with the initials of and the full name of (full name of minor) and date of birth: Alternative Reference: SSN Alternative Reference: FAN Alternative Reference: DLN Alternative Reference: SID Social Security Number (SSN): Financial Account Number (FAN): (DLN): State of Issuance: State Identification Number (SID): American LegalNet, Inc. www.FormsWorkFlow.com CONFIDENTIAL INFORMATION FORM THIS FORM IS CONFIDENTIAL Instructions for Completing the Confidential Information Form The following information is confidential and shall included in anydocument filed with a courtor custodian, except on a Confidential Information Form filed contemporaneously with the document: 1.Social Security Numbers 2.Financial Account Numbers, except an active financial account number may beidentified by the last four digits when the financial account is the subject of thecase and cannot otherwise be identified. includefinancial institution account numbers, debit and credit card numbers, andmethods of authentication used to secure accounts such as personal identificationnumbers, user names and passwords. 3.Driver License Numbers 4.State Identification (SID) Numbers 5. names and dates of birth except when a minor is charged as a defendantin a criminal matter (see 42 Pa.C.S. 247 6355). is a person under the age ofeighteen. 6. Abuse address and other contact information, including name, address and work schedule, in family court actions as defined byPa.R.C.P. No. 1931(a), except for victim's name. is a person forwhom a protection order has been granted by a court pursuant to Pa.R.C.P. No.1901 et seq. and 23 Pa.C.S. 247 6101 et seq. or Pa.R.C.P. No. 1951 et seq. and 42Pa.C.S 247 62A01 et seq. If necessary, this information must be provided onthe separate Abuse Victim Addendum. Please note this form does not need to be filed in types of cases that are sealed or exempted fromaccess pursuant to applicable authority (e.g. juvenile, adoption, etc.). The best way to protect confidential information is not to provide it to the court.Therefore, only provide confidential information to the court when it is required bylaw, ordered by the court or is otherwise necessary to effect the disposition of a matter. Do not include confidential information in any other document filed with the court under thisdocket.If you need to refer to a piece of confidential information in a document, use the alternatereferences. If you need to attach additional pages, sequentially number each alternate referencei.e. SSN 3, SSN 4, etc. This form must be served on all unrepresented parties andcounsel ofrecord. A court or custodian is not required to review or redact any filed document for compliance with . A to comply with this section shall not affect access to caserecords that are otherwise accessible. If a filed document fails to comply with the requirements of the above referenced policy, a court may, upon motion or its own initiative, with or without a hearingthe filed documentsealed, redacted,amended or any combination thereof A court may impose sanctions, including costsnecessary to prepare a compliant document for filing in accordance with applicable authority. American LegalNet, Inc. www.FormsWorkFlow.com CONFIDENTIAL INFORMATION FORM THIS FORM IS CONFIDENTIAL Abuse Victim Addendum The Abuse Victim Addendum a filing where confidential information is being provided byanabuse victim, as defined in this policy, in family court actions (see Pa.R.C.P. No. 1931(a)), as required by or otherwisenecessary to effect the disposition of a matter. This addendum,and any , shall emain confidentia Divorce, Annulment, Dissolution of Marriage Child Custody Support Paternity Protection from Abuse This nformation ertains to: Confidential Information: References in Filing: (full name of abuse victim ) AV Address: AV Name & Address: AV Work Schedule: AV Other contact information: Alternative Reference: AV 1 Address Alternative Reference: AV 1 Name & Address Alternative Reference: AV 1 Work Schedule Alternative Reference: AV 1 Other contact information American LegalNet, Inc. www.FormsWorkFlow.com CONFIDENTIAL INFORMATION FORM THIS FORM IS CONFIDENTIAL Abuse Victim Addendum Additional page (if necessary) D ivorce, Annulment, Dissolution of Marriage Child Custody Support Paternity Protection from Abuse This nformation ertains to: Confidential Information: References in Filing: (full name of abuse victim) AV Address: AV Name & Address: AV Work Schedule: AV Other contact information: Alternative Reference: AV Address Alternative Reference: AV Name & Address Alternative Reference: AV Work Schedule Alternative Reference: AV Other contact information Divorce, Annulment, Dissolution of Marriage Child Custody Support Paternity Protection from Abuse This nformation ertains to: Confidential Information: References in Filing: (full name of abuse victim) AV Address: AV Name & Address: AV Work Schedule: AV Other contact information: Alternative Reference: AV Address Alternative Reference: AV Name & Address Alternative Reference: AV Work Schedule Alternative Reference: AV Other contact information American LegalNet, Inc. www.FormsWorkFlow.com