REQUEST FOR CONFIDENTIALITY –– CIVIL Case No. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Commonwealth of Virginia Va. Code §§ 20-60.3; 20-146.20E TO: [ ] Circuit Court ............................................................................... ................................................................................ v. [ ] Juvenile and Domestic Relations District Court ......................................................................................... In re: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . [ ] Custody Proceeding: I request that the above-named court(s) not disclose, release or allow to be examined any identifying information about me because my health, safety or liberty would be jeopardized by the disclosure of such information. [ ] Support Proceeding: I request that the above-named court(s) not disclose, release or allow to be examined any information about me because [ ] a protective order has been issued [ ] I am at risk of physical or emotional harm from the other party. SHERIFF/PROCESS SERVER: THE INFORMATION CONTAINED IN THIS DOCUMENT IS CONFIDENTIAL AND MAY NOT BE DISCLOSED TO THE PARTIES OR TO THE PUBLIC. ................................................................................................................................................................................... NAME ................................................................................................................................................................................... ADDRESS ................................................................................... DATE OF BIRTH .................................................................................. SOCIAL SECURITY NUMBER ................................................................................................................................................................................... EMPLOYER NAME AND ADDRESS ................................................................................................................................................................................... HOME TELEPHONE NUMBER WORK TELEPHONE NUMBER VIRGINIA DRIVER’S LICENSE NUMBER NOTICE: When a party to a custody proceeding requests that information be kept confidential, this information shall not be released except by order of the court. In support cases where a person requests that information be kept confidential, the information should not be released except by order of the court. ............................................................ DATE OF REQUEST Received on: ............................................. DATE AND TIME ___________________________________________________ SIGNATURE OF PARTY MAKING REQUEST by __________________________________________________ [ ] CLERK/DEPUTY CLERK [ ] MAGISTRATE [ ] INTAKE OFFICER TO THE CLERK: PLACE IN A SEALED ENVELOPE FORM DC-618 REVISED 7/05 American LegalNet, Inc. www.USCourtForms.com