CONFIDENTIAL          
DOCUMENT FORM 

Case Records Public Access Policy of the Unified Judicial System of Pennsylvania
204 Pa. Code § 213.81 
www.pacourts.us/public-records

         _______________________________ 

 (Party name as displayed in case caption) 

     _________________________________ 
      Docket/Case No. 

    Vs. 

 ___________________________________ 

   (Party name as displayed in case caption) 

      _____________________________________ 
      Court  

This form is associated with the pleading titled ___________________________, dated _________________, _____.

Pursuant to the Case Records Public Access Policy of the Unified Judicial System of Pennsylvania, the Confidential Document Form shall 
accompany a filing where a confidential document is required by law, ordered by the court, or is otherwise necessary to effect the 
disposition of a matter. This form shall be accessible to the public, however the documents attached shall not be publicly accessible, 
except as ordered by a court. The documents attached will be available to the parties, counsel of record, the court, and the custodian. 
Please only attach documents necessary for the purposes of this case. Complete the entire form and check all that apply. This form and 
any additional pages must be served on all unrepresented parties and counsel of record.

Type of Confidential Document 

Paragraph, page, etc. where the confidential 
document is referenced in the filing: 

    Financial Source Documents 

 Tax Returns and schedules 

W-2 forms and schedules including 1099 forms or similar documents

    Wage stubs, earning statements, or other similar documents 
    Credit card statements 
    Financial institution statements (e.g., investment/bank statements) 
    Check registers 
    Checks or equivalent 
    Loan application documents 

     Minors’ educational records 
     Medical/Psychological records 
     Children and Youth Services’ records 
     Marital Property Inventory and Pre-Trial Statement as provided in Pa.R.C.P. No. 1920.33 
     Income and Expense Statement as provided in Pa.R.C.P. No. 1910.27(c) 
     Agreements between the parties as used in 23 Pa.C.S. §3105 

I certify that this filing complies with the provisions of the Case Records Public Access Policy of the Unified 
Judicial System of Pennsylvania that require filing confidential information and documents differently than non-
confidential information and documents. 

____________________________________ 
Signature of Attorney or Unrepresented Party

 Date 

______________________________________

 Email: ______________________________________ 

Attorney Number: (if applicable) _________________

   Telephone: __________________________________ 

  Name: 

    Address: 

Rev. 7/2018

   CONFIDENTIAL        
  DOCUMENT FORM 

Instructions for Completing the Confidential Document Form 

The following documents are  confidential and shall be filed with a court or custodian with the
“Confidential Document Form”: 

1. Financial Source Documents as listed on the form

2. Minors’ educational records

3. Medical/Psychological records are defined as “records relating to the past, 
present, or future physical or mental health or condition of an individual”

4. Children and Youth Services’ records

5. Marital Property Inventory and Pre-Trial Statement as provided in Pa.R.C.P. No. 

1920.33

6.

Income and Expense Statement as provided in Pa.R.C.P. No.  1910.27(c)

7. Agreements between the parties as used in 23 Pa.C.S. § 3105 

For each confidential document, list the paragraph, page, etc. where the document is referenced in the 
filing. Please note, this form does not need to be filed in types of cases that are sealed or exempted from 
public access pursuant to applicable authority (e.g. juvenile, adoption, etc.)

 Please only attach documents necessary for the purposes of this case.
 Complete the entire form and check all that apply.
 This form, and any additional pages, must be served on all unrepresented parties and counsel

of record.

A  court  or  custodian  is  not  required  to  review  or  redact  any  filed  document  for  compliance  with  the Case 
Records Public Access Policy of the Unified Judicial System of Pennsylvania.  A  party’s  or  attorney’s  failure
to  comply  shall  not  affect  access  to  case  records  that  are  otherwise accessible. 

If a filed document fails to comply with the above referenced policy, a  court of record may, upon motion or its
own initiative, with or without a hearing,  order the filed document sealed; a magisterial district court may do 
so upon request or its own initiative.  A court of record may impose sanctions, including costs necessary to
prepare a compliant document for filing in accordance with applicable authority.

Rev. 7/2018