Free Affidavit to Withold Identifying Information - West Virginia

NOTICE to Court Personnel: Pursuant to Rule 10(b) of the Rules of Practice and Procedure for Family Court, upon the filing of this affidavit in proper form, the person filing the affidavit, or the person in whose interest the affidavit was filed shall be permitted to withhold identifying information from all persons except court personnel whose duties require access to the information; and shall not be required to provide identifying information in pleadings, forms, document filings, or in any other manner. All court personnel with access to such identifying information shall keep the information confidential, and shall withhold it from all persons except other court personnel whose

IN THE FAMILY COURT OF

COUNTY, WEST VIRGINIA

In re: The Marriage / Children of: ___________________, Petitioner, and ___________________, Respondent. Civil Action No. _____. AFFIDAVIT to Withhold Identifying Information State of West Virginia. County of ___________________. I, __________________________________ , after being sworn, state that the health, safety, or liberty of the persons whose names are listed below would be put at risk by the disclosure of information which could be used to locate these persons, or contact them by telephone, or by other means. Persons at risk are: ____________________________________________________________ __________________________________________________________________________________. These persons are at risk because: _______________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ______________________________________________________________________________.

_____________________ (Print your name.)

_______________________ Signature

___ Petitioner ___ Respondent.

Sworn to before me this ____ day of _________________, 20___. ________________________________ Notary Public My commission expires ____________________.
SCA-FC-140 (12/01) Affidavit to Withhold Identifying Information Page 1 of 1