Con114 - Confidential Information Form
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1
2CONFIDENTIAL
State of Minnesota
District Court
County
Judicial District:
Court File Number:
Case Type:
Juvenile
In the Matter of the Welfare of the Child(ren) of:
Confidential Information Form
__________________________________________
(Form 11.4)
Parent(s)
Legal Custodian(s)
Minn. R. Juv. Prot. P. 8.04, subd. 5
This form shall not be accessible to the public except by court order. This form shall be
accessible to case participants as authorized by the court. This form shall be accessible to
case parties unless it contains information in sections 3 (identity of reporter of abuse) or 4
(HIV-related information), in which case it shall be accessible to the parties as authorized
by the court.
1. Name, address, home, or location of any shelter care or foster care facility in which a
child is placed under a court order.
Reference in
Name of
Shelter/Foster Care Address
Child in
Document
Shelter/Foster Care
Shelter/Foster
Facility or Parent
Care
Shelter Facility or
Foster Parent 1
Shelter Facility or
Foster Parent 2
Shelter Facility or
Foster Parent 3
2. Information that identifies a child as a victim of an alleged or adjudicated sexual
assault.
Child’s First and Last Name
Child’s Date of
Child’s
Child’s
Reference
in
Birth
Gender
Race
document
(mm/dd/yyyy)
Child 1
Child 2
Child 3
Child 4
CON114
State
ENG
8/15
Page 1 of 2
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