Release Of Information - Alaska Page 2
ADVERTISEMENT
1
2AFFIDAVIT and REQUEST for ADDRESS CONFIDENTIALITY
Complete this affidavit only if you want your address and information about your location to be kept
confidential and not released to a person (such as a parent or custodian) who would otherwise be entitled to
have information about your child support case. CSSD will respond in writing with a decision about your
request for confidentiality.
I, ______________________________________________, swear under penalty of perjury that the
following information is true to the best of my knowledge and belief:
1. Name of person I do not want information released to: ________________________ Person’s relationship
to me or the child: _______________________________CSSD case number: ______________________
2. This person has committed domestic violence (threatened, harassed, physically or mentally abused, or
committed sexual assault or incest) against my child or me. Describe who was involved, when, where, and
how it happened:_______________________________________________________________________
_____________________________________________________________________________________
3. A domestic violence protective (restraining) order
has
has not been issued against the person. (If
yes, please provide information about the case): Court case number ______________________
Court
location ___________________________Describe who was involved, when, where, and how it happened:
_____________________________________________________________________________________
______________________________________________________________________________________
4. The person
has
has not
been charged with a crime (such as assault or harassment) or been
involved in a criminal civil or criminal court case in which I was a party, a victim, a witness, or otherwise
involved. (If yes, please provide information about the case): Court case number ___________ Court
location _________________________Describe who was involved, when, where, and how it happened:
_____________________________________________________________________________________
_____________________________________________________________________________________
5. Other information about why I feel threatened by this person and why I want my address kept confidential:
_______________________________________________________________________________________
_____________________________________________________________________________________
Signature ______________________________
Date__________________________
SUBSCRIBED and SWORN to before me this _________ day of _______________________, 20 ______
________________________________________
Notary Public for the State of __________
My commission expires _______________
If you can’t get to a notary, please sign before a witness, and have the witness complete the information below.
I acknowledge that I know the person who signed this form is the person he or she claims to be, and that I witnessed the signature
above.
Witness’s signature _______________________________ Witness’s name (please print) _____________________________
Witness’s Social Security number (optional) ___________________ Witness’s phone ________________________________
Witness’s mailing address ________________________________________________________________________________
th
CSSD main office mailing address: 550 W 7
Ave Suite 310
Anchorage AK
99501-6699
CSSD 04-0502 (Rev. 12/04) (1 p.) Affidavit and Request for Address Confidentiality
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Business