Fill and Sign the Title 18 Human Services Mississippi Secretary of State Form

1051GEJ Approved April 16, 2018 / Revised April 25, 2018 Non-public Information – Parent Identification and Location Page 1 of 1 This is a private record. Non-public Information – Parent Identification and Location Case Number __________________________ Notice: This information is required by the U.S. Secretary of Health and Human Services. If the information changes, you must complete and file another form . (Utah Code 62A- 11-304.4.) This form is accessible only by the other party and any attorneys in the case. The form is not a public record. Name Phone number Residential address [ ] Keep my residential address private and do not provide it to the other party because there is reason to believe that releasing the information may result in physical or emotional harm to me or to my child. (If you check this box, omit your residential address from this document and from all ot her papers filed with the court. Include it only on the Safeguarded Address form.) Mailing address (if different from residential address) Date of birth Social Security Number Driver's license State Number Employer name, address and phone number Employer name, address and phone number I am: (check all that apply) [ ] Petitioner [ ] Respondent [ ] Custodial parent [ ] Non-custodial parent Filing this information about [ ] myself (required) [ ] the other party (optional) I declare under criminal penalty under the law of Utah that everything stated in this documen t is true. Signed at ______________________________________________________ (city, and state or c ountry). Signature ► Date Printed Name