Fill and Sign the Wisconsin Disclosure 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 Enter the name of the petitioner . In re: Petitioner :       First name Middle name Last name and Disclosure of Sealed Identifying Information in a Child Custody Proceeding Case No.       Enter the name of the respondent . Respondent :       First name Middle name Last name Note: Leave case number blank; the clerk will add this. UNDER OATH I STATE THAT: The identifying information about me or my minor children I am requesting to remain sealed because disclosure would jeopardize the health, safety, or liberty of myself or my minor children is as follows: 1.       2.       3.       4.       5.       6.       7.       8.       See attached 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 GF-178, 10/06 Disclosure of Sealed Identifying Information in a Child Custody Proceeding §822.29(5), Wisconsin Statutes This form shall not be modified. It may be supplemented with additional material.This form is used in child custody proceedings with form GF-177. Enter the information you seek to withhold because of your belief that disclosure would jeopardize your health, safety, or liberty, or that of a minor child, such as: address, employer name and address, social security number, etc. 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:       (Seal) FA-4108 Pro Se 01/06 Petition-With Minor Children §§767.085 and 822.09, Wisconsin Statutes This form shall not be modified. It may be supplemented with additional material. Page 2 of 2