Fill and Sign the Affidavit Child Custody Form

PRINT in BLACK ink Enter the name of the county in which you are filing this case. STATE OF WISCONSIN, CIRCUIT COURT,       COUNTY For Official Use Check marriage or paternity, if paternity, enter the initials of the child. In re the marriage of: paternity of       : Enter the name of the petitioner . Petitioner :       First name Middle name Last name and Enter the name of the respondent . Affidavit to Seal Identifying Information in a Child Custody Proceeding Case No.       Respondent :       First name Middle name Last nameNote: Leave case number blank; the clerk will add this. UNDER OATH I STATE THAT: I am involved in a Child Custody Proceeding in which the legal custody, physical placement, or periods of physical placement (visitation) of a child is an issue. My health, safety or liberty, or that of a minor child, WOULD be jeopardized by disclosure of identifying information on court forms that I am filing. State factual basis :       See attached I am attaching on court form GF-178 in a sealed envelope the specific pieces of information that I believe should be sealed. I understand that the information may not be disclosed to the other party or the public unless the court orders the disclosure to be made after a hearing. At that hearing the court will take into consideration the health, safety or liberty of the party or a minor child and determine whether disclosure of the information is in the interest of justice. STOP! Take this document to a Notary Public BEFORE you sign it. After you have been sworn by a Notary Public, sign and print your name and date the document in front of the Notary Public. Signature       Print or Type Name       Date Have the Notary Public sign, date, and seal the document. Subscribed and sworn to before me on       Notary Public, State of Wisconsin My commission expires:       GF-177, 10/06 Affidavit to Seal Identifying Information in a Child Custody Proceeding §§767.085 and 822.29(5), Wisconsin Statutes This form shall not be modified. It may be supplemented with additional material.This form applies only in child custody proceedings. It allows the sealing of identifying information that you feel would endanger your health safety or liberty. Any and all information you choose not to include on the divorce/legal separation papers must be included on form GF- 178 in the sealed env.