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IN THE DISTRICT COURT OF ______________ COUNTY, KANSAS

____________________, Plaintiff vs. ____________________, Defendant Case No. _______________

PROTECTION FROM ABUSE CONFIDENTIAL FORM

NOTE:IF THE COURT FINDS THAT THE PLAINTIFF'S ADDRESS AND TELEPHONE NUMBER NEED TO REMAIN CONFIDENTIAL FOR THE PROTECTION OF THE PLAINTIFF OR THE MINOR CHILDREN, THIS FORM WILL BE SHOWN ONLY TO AUTHORIZED COURT OR LAW ENFORCEMENT PERSONNEL AND WILL NOT BE DISCLOSED TO THE PUBLIC OR TO THE DEFENDANT. IT IS THE PLAINTIFF'S RESPONSIBILITY TO NOTIFY THE COURT OF ANY CHANGE IN ADDRESS OR TELEPHONE NUMBER.

Name of Plaintiff:

Confidential Address:

Street City ________________________ State ________________ Phone Number ______________________ Zip Code

07/10/04