© Superior Court of Arizona in Maricopa County DRSDS10f-c- 071519
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Person Filing:
Address (if not protected):
City, State, Zip Code:
Telephone:
Email Address:
ATLAS Number:
Lawyer’s Bar Number:
Representing Self, without a Lawyer or Attorney for Petitioner OR Respondent
SUPERIOR COURT OF ARIZONA
IN MARICOPA COUNTY
Case No.
Petitioner / Party A
ATLAS No.
Respondent / Party B
FAMILY DEPARTMENT SENSITIVE DATA
COVERSHEET WITH CHILDREN
(CONFIDENTIAL RECORD)
Fill out. File with Clerk of Superior Court. Social Security Numbers should appear on this form only and
should be omitted from other court forms. Access Confidential pursuant to ARFLP 43.1(f).
A.
Personal Information:
Respondent / Party B
Name
Gender
Male or Female
Male or Female
Date of Birth (Month/Day/Year)
Social Security Number
Warning: DO NOT INCLUDE MAILING ADDRESS ON THIS FORM IF REQUESTING ADDRESS PROTECTION
Mailing Address
City, State, Zip Code
Contact Phone
Receive texts from Court to
contact phone number above?
Yes No texts Yes
No texts
Email Address
Current Employer Name
Employer Address
Employer City, State, Zip Code
Employer Telephone Number
Employer Fax Number
B. Child(ren) Information:
Child Name
Gender
Child Social Security Number
Child Date of Birth
C. Type of Case being filed: Mark only one (1) category below. (*) Mark this box only if no other case type applies.
Dissolution (Divorce)
Paternity
Order of Protection
Legal Separation
*
Legal Decision-Making
/ Parenting Time
Register Foreign Order
Annulment
*Child Support
Other
D. Do you need an interpreter? Yes or No. If Yes, what language? _____________________
DO NOT COPY this document. DO NOT SERVE THIS DOCUMENT to the other party.
For Clerk’s Use Only