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P R IN T i n B LA C K i n k G F-1 7 8, 1 0/0 6 D is clo su re o f S eale d Id entif y in g In fo rm atio n in a C hil d C usto dy P ro ce edin g §82 2.2 9(5 ), W is co nsin S ta tu te s T his f o rm s h all n o t b e m od if ie d . I t m ay b e s u pple m en te d w it h a d dit io nal m ate ria l. E nte r t h e n am e o f t h e c o unty i n w hic h y o u a re f ilin g t h is c ase . S TA TE O F W IS C O NSIN , C IR CUIT C O URT, C O UNTY E nte r t h e n am e o f t h e p etit io n er. F or O ff ic ia l U se In r e : P etit io ner: F ir s t n am e M id dle n am e L ast n am e a nd E nte r t h e n am e o f t h e r esp on d en t. N ote : L eav e c ase n u m ber b la n k; t h e c le rk w ill a d d t h is . R esp onden t: F ir s t n am e M id dle n am e L ast n am e D is clo su re o f S ea le d I d en tif y in g In fo rm atio n in a C hild C usto d y P ro ceed in g C ase N o. U NDER O ATH I S TA TE T H AT: T he id entif y in g in fo rm atio n a bou t m e o r m y m in or c h ild re n I a m r e questin g t o r e m ain s e ale d b eca use d is clo su re w ou ld je opard iz e t h e h ea lt h , s a fe ty , o r li b erty o f m ys e lf o r m y m in or c h ild re n i s a s f o llo w s: 1 . 2 . 3 . 4 . 5 . 6 . 7 . 8 . S ee a tta ch ed ST O P! T ak e t h is d ocu m en t t o a N ota ry P ublic B EFO RE y ou s ig n i t . Afte r y o u h av e b een s w orn b y a N ota ry P ublic , s ig n a n d p rin t y o ur n am e a n d d ate t h e d o cu m en t i n f r o nt o f t h e N ota ry P ublic . S ig natu re Prin t o r T yp e N am e D ate H av e t h e N ota ry P ub lic s ig n , d ate , a n d s e al t h e d ocu m en t. Subscrib ed a nd s w orn to b efo re m e o n N ota ry P ublic , S ta te o f W is co nsin M y c o m m is s io n e xp ir e s: ( S ea l) T his f o rm i s u se d i n c h ild c u sto dy p ro ceed in gs w ith f o rm G F-1 77. E nte r t h e i n fo rm atio n y o u s e ek t o w ith hold b ecau se o f y o ur b elie f t h at d is c lo su re w ould j e o p ard iz e y o ur h ealth , s a fe ty , o r l ib erty , o r t h at o f a m in or c h ild , s u ch a s: a d dre ss, e m plo yer n am e a n d a d dre ss, s o cia l s e cu rity n um ber, e tc .