SCA-FC-140 (12/01) Affidavit to Withhold Identifying Information Page 1 of 1
NOTICE to Court Personnel:
Pursuant to Rule 10(b) of the Rules of Practice and Procedure for Family Court, upon the filing
affidavit in proper form, the person filing the affidavit, or the person in whose interest the affidavit was filed shall
be permitted to withhold identifying information from all persons except court personnel whose duties require
access to the information; and shall not be required to provide identifying information in pleadings, forms,
document filings, or in any other manner. All court personnel with access to such identifying information shall
keep the information confidential, and shall withhold it from all persons except other court personnel whose duties
require access to the information.
IN THE FAMILY COURT OF COUNTY, WEST VIRGINIA
In re: The Marriage / Children of:
___________________, Petitioner, and ___________________, Respondent.
Civil Action No. _____.
Withhold Identifying Information
State of West Virginia.
County of ___________________.
I, __________________________________ , after being sworn, state that the health, safety, or
liberty of the persons whose names are listed below would be put at risk by the disclosure of information
which could be used to locate these persons, or contact them by telephone, or by other means. Persons at
risk are: ____________________________________________________________
These persons are at risk because: _______________________________________________________
_____________________ _______________________ ___ Petitioner ___ Respondent.
(Print your name.) Signature
Sworn to before me this ____ day of _________________, 20___.
My commission expires ____________________.