CONFIDENTIAL 
INFORMATION 
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 
Information Form shall  accompany a filing where confidential information is required by law, ordered by the court, or 
otherwise necessary to effect the disposition of a matter.  This form, and any additional pages, shall remain confidential, 
except that it shall be available to the parties, counsel of record, the court, and the custodian.  This form, and any 
additional pages, must be served on all unrepresented parties and counsel of record. 

This Information Pertains to:

Confidential Information: 
Social Security Number (SSN): 

_____________________________ 
(full name of adult)  

OR 
This information pertains to a 
minor with the initials of ____ 
and the full name of  

_____________________________ 
Financial Account Number (FAN): 

_____________________________ 
Driver License Number (DLN): 

_____________________________ 
(full name of minor) 

_____________________________    
State of Issuance: 

References in Filing: 

Alternative Reference:  
SSN 1 

Alternative Reference: 
FAN 1 

Alternative Reference: 
DLN 1 

    and date of birth: __________ 

_____________________________ 
State Identification Number (SID):  

_____________________________ 

Social Security Number (SSN): 

_____________________________ 
Financial Account Number (FAN): 

_____________________________ 
Driver License Number (DLN): 

Alternative Reference: 
SID 1 

Alternative Reference:  
SSN 2 

Alternative Reference: 
FAN 2 

Alternative Reference: 
DLN 2 

_____________________________ 
(full name of adult)  

OR 
This information pertains to a 
minor with the initials of ____ 
and the full name of  

_____________________________ 
(full name of minor) 

_____________________________    
State of Issuance: 

     and date of birth: __________ 

_____________________________ 
State Identification Number (SID):  

_____________________________ 

Alternative Reference: 
SID 2 

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THIS FORM IS CONFIDENTIAL 

CONFIDENTIAL 
INFORMATION 
FORM 

Additional page(s) attached. 

total pages are attached to this filing. 

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 

             __________________________________
Name:

Attorney Number: (if applicable)

Address: __________________________ 

Telephone: 

_________________________________________

Email:

________________________________________________

NOTE: Parties and attorney of record in a case will have access to this Confidential Information
Form. Confidentiality of this information must be maintained.

Rev. 7/2018

THIS FORM IS CONFIDENTIAL 

CONFIDENTIAL 
INFORMATION 
FORM 

Additional page (if necessary) 

This Information Pertains to:

Confidential Information: 
Social Security Number (SSN): 

_____________________________ 
(full name of adult)  

OR 
This information pertains to a 
minor with the initials of ____ 
and the full name of  

_____________________________ 
Financial Account Number (FAN): 

_____________________________ 
Driver License Number (DLN): 

_____________________________ 
(full name of minor) 

_____________________________ 
State of Issuance: 

References in Filing: 

Alternative Reference:  
SSN ___ 

Alternative Reference: 
FAN ___ 

Alternative Reference: 
DLN ___ 

    and date of birth: __________ 

_____________________________ 
State Identification Number (SID):  

_____________________________ 

Social Security Number (SSN): 

_____________________________ 
Financial Account Number (FAN): 

_____________________________ 
Driver License Number (DLN): 

Alternative Reference: 
SID ___ 

Alternative Reference:  
SSN ___ 

Alternative Reference: 
FAN ___ 

Alternative Reference: 
DLN ___ 

_____________________________ 
(full name of adult)  

OR 
This information pertains to a 
minor with the initials of ____ 
and the full name of  

_____________________________ 
(full name of minor) 

_____________________________ 
State of Issuance: 

     and date of birth: __________ 

_____________________________ 
State Identification Number (SID):  

_____________________________ 

Alternative Reference: 
SID ___ 

_____________________________ 
(full name of adult)  

OR 
This information pertains to a 
minor with the initials of ____ 
and the full name of  

Social Security Number (SSN): 

_____________________________ 
Financial Account Number (FAN): 

_____________________________ 
Driver License Number (DLN): 

Alternative Reference:  
SSN ___ 

Alternative Reference: 
FAN ___ 

Alternative Reference: 
DLN ___ 

_____________________________ 
(full name of minor) 

_____________________________ 
State of Issuance: 

     and date of birth: __________ 

_____________________________ 
State Identification Number (SID):  

_____________________________ 

Alternative Reference: 
SID ___ 

Rev. 7/2018

THIS FORM IS CONFIDENTIAL 

CONFIDENTIAL 
INFORMATION 
FORM 

Instructions for Completing the Confidential Information Form 

The following information is confidential and shall not be included in any  document filed with a court 
or custodian, except on a Confidential Information Form filed contemporaneously with the document: 

Social Security Numbers

1.

2.

3.

4.

5.

6.

Financial Account Numbers, except an active financial account number may be
identified by the last four digits when the financial  account is the subject of the
case and cannot otherwise be  identified. “Financial Account Numbers” include
financial institution account numbers, debit and credit card numbers, and
methods of authentication used to secure accounts such as personal identification
numbers, user names and passwords.

Driver License Numbers

State Identification (SID) Numbers

Minors’ names and dates of birth except when a minor is charged  as a defendant
in a criminal matter (see 42 Pa.C.S. § 6355). “Minor” is a person under the age of
eighteen.

Abuse victim’s address and other contact information, including employer’s
name, address and work schedule, in family court  actions as defined by
Pa.R.C.P. No. 1931(a), except for victim's name. “Abuse Victim” is a person for
whom a protection order has been granted by a court pursuant to Pa.R.C.P. No.
1901 et seq. and 23 Pa.C.S. § 6101 et  seq. or Pa.R.C.P. No. 1951 et seq. and 42
Pa.C.S § 62A01 et seq. If necessary, this information must be provided on
the separate Abuse Victim Addendum. Please note there are separate
instructions for the completion of the Addendum located on the form.

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.).

 The best way to protect confidential information is not to provide it to the court.

Therefore, only provide confidential information to the court when it is required by
law, ordered by the court or is otherwise necessary to effect the disposition of a matter.

 Do not include confidential information in any other document filed with the court under this

docket.



If you need to refer to a piece of confidential information in a document, use the alternate
references. If you need to attach additional pages, sequentially number each alternate reference
– i.e. SSN 3, SSN 4, etc.

 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 with this section shall not affect access to case records that are otherwise accessible. 

If a filed document fails to comply with the requirements of 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, redacted, amended or any combination thereof; a magisterial district court may, upon request or 
its own initiative, redact, amend or both.  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

THIS FORM IS CONFIDENTIAL 

CONFIDENTIAL 
INFORMATION 
FORM 

  Abuse Victim Addendum 

Instructions for Completing the Abuse Victim Addendum: The Abuse Victim Addendum shall accompany 
a filing where confidential information is being provided by an abuse victim, as defined in this policy, in 
family court actions (see Pa.R.C.P. No. 1931(a)), as required by law, ordered by the court, or otherwise 
necessary to effect the disposition of a matter. This addendum, and any additional pages, shall only be 
provided to the court and shall remain confidential. The best way to protect confidential information is not to 
provide it to the court. Therefore, only provide confidential information to the court when it is required by law, 
ordered by the court or is otherwise necessary to effect the disposition of a matter.

Type of Family Court Action

Divorce, Annulment, Dissolution of Marriage 

Child Custody 
 

Support 

Paternity 

Protection from Abuse 

This Information Pertains to: 

Confidential Information: 

References in Filing: 

AV Address: 

Alternative Reference: 
AV 1 Address 

  _____________________________ 

 (full name of abuse victim) 

AV Employer’s Name & Address: 

Alternative Reference: 
AV 1 Employer’s Name & Address 

______________________________ 
Docket/Case No. of Protection Order

AV Work Schedule: 

Alternative Reference: 
AV 1 Work Schedule 

______________________________
Court/County

AV Other contact information: 

Alternative Reference: 
AV 1 Other contact information 

Attach additional page(s) if necessary. 

Rev. 7/2018

THIS FORM IS CONFIDENTIAL 

CONFIDENTIAL 
INFORMATION 
FORM 

  Abuse Victim Addendum 
Additional page (if necessary) 

Type of Family Court Action

Divorce, Annulment, Dissolution of Marriage 

Child Custody   

Support  

 Paternity 

Protection from Abuse 

This Information Pertains to: 

Confidential Information: 

References in Filing: 

AV Address: 

Alternative Reference: 
AV __ Address

  _____________________________ 
 (full name of abuse victim) 

AV Employer’s Name & Address: 

Alternative Reference: 
AV __ Employer’s Name & Address

______________________________ 
Docket/Case No. of Protection Order

AV Work Schedule: 

______________________________
Court/County

AV Other contact information: 

Alternative Reference: 
AV __Work Schedule

Alternative Reference: 
AV __ Other contact information

 Divorce, Annulment, Dissolution of Marriage 

 Child Custody 

Type of Family Court Action

Support  

 Paternity

 Protection from Abuse 

This Information Pertains to: 

Confidential Information: 

References in Filing: 

AV Address: 

Alternative Reference: 
AV __ Address

  _____________________________ 
 (full name of abuse victim) 

AV Employer’s Name & Address: 

Alternative Reference: 
AV __ Employer’s Name & Address

______________________________ 
Docket/Case No. of Protection Order

AV Work Schedule: 

Alternative Reference: 
AV __Work Schedule

______________________________
Court/County

AV Other contact information: 

Alternative Reference: 
AV __ Other contact information

Rev. 7/2018

THIS FORM IS CONFIDENTIAL