Confidential Information Form (Info) (Page 2 of 2) in pdf

Confidential Information Form (Info) Page 2

2) Child's Name (Last, First, Middle)

Child's Race/Sex/Birthdate

Child's Soc. Sec. No. (If required)

Child's Present Address or Whereabouts

List the names and present addresses of the persons with whom the child(ren) lived during the last five

years:

List the names and present addresses of any person besides you and the respondent who has physical

custody of, or claims rights of custody or visitation with, the child(ren):

Except for petitions in protection order cases (Domestic Violence/Antiharassment/

Sexual Assault), the following information is required:

Petitioner's Information

Respondent's Information

Soc. Sec. No.:

Residential Address (Street, City, State, Zip)

E-mail Address:

Telephone No.: (

)

Telephone No.: (

)

Employer:

Empl. Address:

Empl. Phone No.: (

)

Empl. Phone No.: (

)

For Nonparental Custody Petitions only, list other Adults in Petitioner(s) household (Name/DOB):

Additional information:

ddendum(s) To Confidential Information Form attached. List other parties or children in Addendum(s).

I certify under penalty of perjury under the laws of the state of Washington that the above information is

true and accurate concerning myself and is accurate to the best of my knowledge as to the other party, or

is unavailable. The information is unavailable because

Signed on __________________ (Date) at ____________________________________ (City and State).

Petitioner/Respondent

WPF DRPSCU 09.0200 Confidential Information Form (INFO) (07/2011) RCW 26.23.050- Page 2 of 2

Confidential Information Form (Info) Page 2