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      FL-5 11GOVER NM EN TA L A G EN C Y ( p urs u ant to W elf . & In st. C ode, § § 1 1475.1 , 1 1478.2 ) o r A TTO RNEY O R P AR TY W IT H O UTFO R C O URT U SE O NLYA TTO RNEY ( N am e, s ta te b ar n um ber, a nd a ddre ss):(P arty a p pearin g w it h out a n a tto rn ey s h ould e nte r in th is s p ace th e s a m e a ddre ss lis te d in it e m 3 , b elo w .)T E LE PH O NE N O .FA X N O .ATTO RNEY F O R ( N am e):S U PER IO R C O URT O F C ALIF O RNIA , C O UNTY O FSTR EET A D DR ESSM AIL IN G A D D RESSC IT Y A N D Z IP C O DEBR AN CH N AM EP ETIT IO NER :RESPO NDEN T:O TH ER : E X P A RTE A PPLIC ATIO N F O R O RDER F O R NONDIS C LO SU RE O F A DDRESS A ND O RDER ( U IF S A ) CASE N UM BER1 .(N am e):a pplie s f o r a n o rd er f o r n ondis clo su re o f t h eaddre ss o r o th er id entif y in g in fo rm atio n o f ( n am e):in t h e p le a din gs a n d o th er d ocu m en ts t o b e f ile d in t h is a ctio n.2.T he d is tr ic t a tto rn e y a ctin g o n b eha lf o f ( n am e): fo r n ondis clo su re o f t h e a ddre ss o r o th er id entif y in g in fo rm atio n o f ( n am e): in t h e p le a din gs a n d o th er d ocu m en ts t o b e f ile d in t h e U IF S A a ctio n .applie s f o r a n o rd er3. T he f o llo w in g is t h e m ailin g a ddre ss f o r s e rv ic e o f p ro ce ss o n ( n am e):4 . F acts in s u pport o f t h is a pplic a tio n ( s ta te f a cts t h at d em onstr a te t h at t h e h ealt h , s a fe ty , f r e edom o f m ove m ent, o r p hysic a l o rem otio n al w ell- b e in g o f th e a pplic a nt o r t h e a pplic a nt's c h ild m ay b e u nre aso nably p ut a t r is k b y t h e d is clo su re o f th e a pplic a nt's ad dre ss o r o th er id entif y in g in fo rm atio n):c o nta in ed in t h e a tta ch ed d ecla ra tio nI d ecla re u nder p e nalt y o f p erju ry u nder t h e la w s o f t h e S ta te o f C alif o rn ia t h at t h e f o re goin g is t r u e a nd c o rre ct.D ate :(T Y PE O R P R IN T N AM E)(S IG NATU RE O F D EC LA R AN T)E X P A RTE A PP LIC ATIO N F O R O RDER F O R NONDIS C LO SU RE O F A DDRESS A ND O RDER (U IF S A )Fam ily C ode, § 4 977Form Adopted by for Optional Use Judicial Council of California FL-511 [Rev. January 1, 2003]ele ctr o nic f o rm  2 002 WWW.LawCA.com La w P ublis h erspage1 of 2         PETIT IO NER :CASE N UM BERR ESPO NDEN T:O TH ER :TH E C O URT F IN DS:5.T he h ealt h , s a fe ty , o r lib erty o f ( n am e):w ould b eunre aso nably p ut a t r is k b y t h e d is clo su re o f h is o r h er a ddre ss o r o th er id entif y in g in fo rm atio n t h at m ay le ad t o h is o r h er where abouts .6 .T he a pplic a tio n is n ot s u ffic ie nt t o g ra nt t h e r e queste d r e lie f.T H E C O URT O RDER S:7.T he a ddre ss o r o th er id entif y in g in fo rm atio n t h at m ay le ad t o t h e w here abouts o f ( n am e): sh all n ot b e d is clo se d in t h e p le adin gs o r d ocu m ents f ile d int h is a ctio n.8.T he a pplic a tio n is d enie d.9.O th er ( s p ecif y ):D ate :JU DIC IA L O FFIC ERN O TE : U se o f t h is e x p arte a p plic atio n a n d o rd er w ill r e q uir e t h at t h e U IF S A p etit io n i n t h is m atte r b e i n it ia te d i n t h e Calif o rn ia c o urt i n w hic h t h is a p plic atio n i s s u bm it te d p urs u an t t o F am ily C ode s ectio ns 4 907 a n d 4 918.E X P A RTE A PP LIC ATIO N F O R O RDER F O R NONDIS C LO SU RE O F A DDRESS A ND O RDER (UlF S A )FL-511 [Rev. January 1, 2003]page2 of 2ele ctr o nic f o rm  2 002 WWW.LawCA.com La w P ublis h ers