Nondisclosure Of Identifying Information Affidavit
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1NONDISCLOSURE OF IDENTIFYING INFORMATION AFFIDAVIT
I, ______________________________________________, swear under penalty of perjury that the
following information is true to the best of my knowledge and belief.
1. Name of Obligor and Child Support Enforcement Case Number:
_______________________________
________________________________________
2.
Who will be protected by withholding identifying information? Please list your name and your
child(ren)’s names:
________________________________
_______________________________________
________________________________
_______________________________________
________________________________
_______________________________________
3. Have you or your child(ren) ever felt threatened by harassment, threats, mental or emotional abuse,
or physical violence, including sexual assault or incest? Please explain when you felt this way, and
describe who was involved, when, where, and how it happened.
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
4.
Is there a restraining order in effect now for domestic violence?
_____Yes
_____No
If yes, include a copy when you return this form.
Case number ________________Court/judicial district _______________________________
5.
Was there a restraining order in the past for domestic violence ? _____Yes
_____No
If yes, please write the case number and information about the case below, such as who was
involved, when, where, and how
it happened.
Case number __________________________Court/judicial district______________________
________________________________________________________________________________
6.
Were you ever involved in a criminal assault case with the other party as the defendant?
_____Yes
_____No
If yes, please write the case number and information about the case below, such as who was
involved, when, where, and how
it happened.
Case number ___________________Court/judicial district____________________________
________________________________________________________________________________
7.
Is there any other information you can give to show why you feel threatened by the other party in
your child support case?
___________________________________________________________________________
___________________________________________________________________________
__________________________________________
___________________________
Signed
Date
SUBSCRIBED and SWORN to before me this _________ day of ________________________, 20 ______.
_______________________________________________
Notary Public for the State of _______________________
My commission expires ___________________________
Witness (Print Name)_____________________________________
Witness Signature________________________________________ Date Signed__________________________________________
Witness Address_________________________________________ Zip Code_____________________________________________
Telephone #___________________________________ Social Security # (Optional) ________________________________________
I willingly state that I know the person who has signed this form to be the person that he/she states he/she is and I have witnessed their signature on this
form.
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