Non Disclosure Addendum Uniform Child Custody Jurisdiction Act {DC-621}

THIS IS CONFIDEN TIAL INFORM ATION NON-DISCLOSURE ADDENDUM Case No. ....................................................................... Commonwealth of Virginia [ ] PROTECTIVE ORDER IN PROTECTIVE ORDER CASES, THIS INFORMATION SHALL NOT BE RELEAS ED EXCEPT BY COURT ORDER OR WHEN NECESSAR Y FOR USE BY LAW ENFORCEMENT. [ ] UCCJEA AFFIDAVIT IN CASES IN WHICH A UCCJEA AFFIDAVIT IS REQUIRED AND A PERSON REQUESTS THAT INFORMATION BE KEPT CONFIDENTIAL, THIS INFORMATION SHALL NOT BE RELEASED EXCEPT BY ORDER OF THE COURT. [ ] PETITION FOR SUPPORT [ ] MOTION TO AMEND [ ] MOTION FOR SHOW CAUSE IN SUPPORT CASES WHERE A PERSON REQUESTS THAT INFORMATION BE KEPT CONFIDENTIAL, THE INFORMATION SHOULD NOT BE RELEASED EXCEPT BY ORDER OF THE COURT. SHERI FF: WHEN USED FOR SERVI CE , PLE ASE DESTR OY THIS DOCUM ENT AFTE R SERV ICE IS MADE. In re: ........................................................................ ................................................................................................ CHILD ........................................................................ ............. v. ........................................................................ .............. ........................................................................ .......................................................................................................... NAME OF PERSON WHOSE INFORMATION IS TO BE PROTECTED ........................................................................ .......................................................................................................... ADDRESS ........................................................................ .......................................................................................................... ........................................................................ ........................................................................................... HOME TELEPHONE NUMBER WORK TELEPHONE NUMBER SUPPORT CASES ONLY Va. Code 20-60.3 Include this information for the person whose information is to be protected. DCSE ID No.: .............................................................. Social Security No.: ......................................................Drivers License No. and State: ................................................... Date of Birth: ................................................................ UCCJE A AFFIDAV IT USE ONLY Va. Code 20-146.20E In addition to above, complete only the information that has been omitted from the DC-620, AFFIDAVIT form: 1. The child presently resides at: ........................................................................ ........................................................... ADDRESS The child commenced residing there on ....................................................... and has resided there continuously to this date. DATE 2. The other places where and persons with whom this child has lived during the last five (5) years include: ........................................................................ .................................................................................................... 3. I know of a person who is not already named as a party in this proceeding who has physical custody of this child or who claims to have custody or visitation rights with respect to the child. The name and address of that person is: ........................................................................ .................................................................................................... 4. Anything else from the affidavit not contained above: ........................................................................ .................................................................................................... American LegalNet, Inc.FORM DC-621 (PAGE ONE OF ONE) 05/04 PDF www.USCourtForms.com