This is a private record. 

Non-public Information – Minors 
Utah Code of Judicial Administration Rule 4-202.02 

Case No. _________________________ 

Use this document to provide non-public information to the court. Write the information here, and omit it 
from the public document. Complete as many forms as needed. Serve this form on the other party. 

I swear or affirm that the following information is true. 

[  ]  * Keep the residential address private and do not provide it to the other party 
because there is reason to believe that releasing the information may result in physical 
or emotional harm to me or to my child.  
(If you check this box, do not include the child’s residential address on this document or any other papers 
filed with the court. Include it only on the Safeguarded Address form.) 

. Name of minor 

Date of birth 

Sex 
 

 

Social Security 
Number 

Residential address* 
 

The following information is required only if custody or parent time is part of the case. 

Child’s name 

Address (street, 
city, state, ZIP) 

Dates child 
lived at this 
address 

Name(s) of person(s) 
who lived with child at 
this address 

Relationship(s) to 
child 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

. Name of minor 

Date of birth 

Sex 
 

 

Social Security 
Number 

Residential address* 
 

The following information is required only if custody or parent time is part of the case. 

Child’s name 

Address (street, 
city, state, ZIP) 

Dates child 
lived at this 
address 

Name(s) of person(s) 
who lived with child at 
this address 

Relationship(s) to 
child 

1052GEJ Approved April 16, 2018 / 
Revised October 10, 2019 
 

Non-public Information – Minors 

Page 1 of 2 

  1

 

 

 

 

 

  2

 

 

 

 

Date of birth 

 

Sex 
 

 

Social Security 
Number 

The following information is required only if custody or parent time is part of the case. 

Child’s name 

Address (street, 
city, state, ZIP) 

Dates child 
lived at this 
address 

Name(s) of person(s) 
who lived with child at 
this address 

Relationship(s) to 
child 

 
 
 
3. Name of minor 
 

Residential address* 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

etitioner or Respondent  

I declare under criminal penalty under the law of Utah that everything stated in this document is true. 

Signed at ______________________________________________________ (city, and state or country). 

 

 

 

 

 

 

 

 

 

Signature ► 

Printed Name 

Signature ► 

Printed Name 

Attorney or Licensed Paralegal Practitioner of record (if applicable) 

 

 

 

 

        P

   

 
Date 

 
Date 

 

1052GEJ Approved April 16, 2018 / 
Revised October 10, 2019 
 

Non-public Information – Minors 

Page 2 of 2