Confidential Disclosure Of Protected Information {GF-241}

CONFIDENTIAL COURT RECORD GF-241, 11/17 Confidential Disclosure of Protected Information 247801.19(2), Wisconsin Statutes This form shall not be modified. It may be supplemented with additional material. Enter the name of the county in which this case is filed. STATE OF WISCONSIN, CIRCUIT COURT, COUNTY Enter the Petitioner/ Petitioner/Plaintiff : First name Middle name Last name Enter the Respondent/ Enter the case number. Use this form to provide protected information to the court: social security, employer or tax ID, driver license, financial accounts, and passport numbers. Confidential Disclosure of Protected Information Case No. Respondent/Defendant : First name Middle name Last name For family and paternity cases, use form GF - 179, Confidential Petition Addendum, to protect social security numbers. This form is used for all case types. Some information may not apply to your case. 1 . The following protected information is needed for this case or is required by law. It has been omitted or redacted from documents filed with the court. A . Name: Social Security number: Employer or taxpayer ID number: Driver license number: In #1, enter the name of each person whose protected information is needed for this case and the information to be protected. Financial account numbers: Passport number: B . Name: Social Security number: Employer or taxpayer ID number: Do NOT use th is form if the information is not needed for this case. Just omit the protected information from the documents you file or blank it out from the copies filed with the court. Keep the unredacted original documents. Driver license number : Financial account numbers: Passport number: C. Name: Social Security number: Employer or taxpayer ID number: Driver license number: Financial account numbers: Passport number: See attached for additional parties In #2, if it is not practical to redact a document, you may attach it to this form without redacting it. See 247801.19(2)(c)3, Wis. Stats. In #3, if you are not a party or the attorney for a party, describe your relationship to this case. 2. The following documents cannot be redacted and are attached: 3. I am not an attorney or a party to this case. I am interested because: Signature Sign and print your name and date the document. Print or Type Name Relationship to C ase Date American LegalNet, Inc. www.FormsWorkFlow.com