Request For Privacy Protection Form - Department Of Children And Families (Page 2 of 2) in pdf

Request For Privacy Protection Form - Department Of Children And Families Page 2

DCF-F-DWSC11376 (R. 08/2015)

Request for Privacy Protection

(please print)

YOUR KIDS PIN __________________________ and Birth Date ___________________________________

or your Social Security Number * ________________________________________________________

Name of person completing this form ___________________________________________________________

Address __________________________________________________________________________________

Please list the person(s) whose whereabouts must be kept private. Include yourself and/or your children, as

appropriate.

Name (First, Last)

KIDS Pin #

Birth Date

*Social Security #

Please list the full name and your relationship to the person from whom the information should be kept

Name ______________________________________________ Relationship __________________________

Please check () your reason for seeking protection:

 I am covered by a protective order in ___________________________________________ County.

 Release of information about my child or me may result in physical or emotional harm to my child

or me.

Please explain briefly ______________________________________________________________

________________________________________________________________________________

 I have been granted good cause for non-cooperation with child support in ______________ County

I understand that this request for privacy protection applies to use of my information by the Child Support

Agency staff only, and is contingent upon approval of this application. I acknowledge that this application does

not extend to the court. In order to obtain privacy protection for court purposes, I know that I must complete a

separate form and have it approved.

Date ____________________ Signature _______________________________________________________

* Provision of your Social Security Number (SSN) is voluntary; not providing it could result in an information

processing delay.

Request For Privacy Protection Form - Department Of Children And Families Page 2