CONFIDENTIAL INFORMATION FORM (Required by SDCL 15-15A-9) ________________________________________________ Plaintiff/Petitioner ________________________________________________ Defendant/Respondent The information on this form is protected and shall not be placed in a publicly accessible portion of the court record. The filing documents will be placed in the public part of the court record devoid of this information. NAME SOCIAL SECURITY NUMBER, EMPLOYER IDENTIFICATION NUMBER, TAXPAYER IDENTIFICTION NUMBER, FINANCIAL ACCOUNT NUMBERS, and MEDICAL ACCOUNT NUMBERS Case No. _______________________ Plaintiff/Petitioner 1. Defendant/Respondent 1. Others Parties (including minor children) 1. 2. 3. 4. 5. 6. 7. 8. Information supplied by : ________________________________________________________________ Signed: _________________________________________________________ Firm: Address: Date: Form UJS-104 Rev. 10/2016 American LegalNet, Inc. www.FormsWorkFlow.com