This is a safeguarded record. 

Case Number ______________________ 

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

Instructions:  

If your case is one of the types listed below and you want to safeguard your contact information (or that of 
your child) from the other party, write the information on this form and omit the information from the other 
documents you file in the case. File this form with the court, but do not serve this form on the other party. 

Keep the following contact information private. Do not provide the contact information to 
the other party because (Choose all that apply.): 

[  ] 

I have a court order or agency order authorizing me to safeguard my contact 
information. 

[  ] 

this proceeding is about: 

 a protective order (Utah Code 78B-7-109). 
 a stalking injunction (Utah Code 78B-7-701). 
  a parentage order (Utah Code 62A-11-304.4). 
 a custody order (UCCJEA, Utah Code 78B-13-209). 
 a support order (UIFSA, Utah Code 78B-14-312). 

Reason for safeguarding contact 
information 

[  ] court or agency order  
[  ] protective order  
[  ] stalking injunction  

[  ] parentage order  
[  ] custody order (UCCJEA) 
[  ] support order (UIFSA) 

Email address 

 

 

Reason for safeguarding contact 
information 

[  ] court or agency order  
[  ] protective order  
[  ] stalking injunction  

[  ] parentage order  
[  ] custody order (UCCJEA) 
[  ] support order (UIFSA) 

Email address 

1053GEJ Approved April 16, 2018 / 
Revised December 20, 2021 

Non-public Information – Safeguarded Contact 
Information 

Page 1 of 2 

 

 

 

 

 

 

 

 

 

Residential Address 

City, State, ZIP 

Phone 

ame 

  N

Residential Address 

City, State, ZIP 

Phone 

ame 

  N

Reason for safeguarding contact 
information 

[  ] court or agency order  
[  ] protective order  
[  ] stalking injunction  

[  ] parentage order  
[  ] custody order (UCCJEA) 
[  ] support order (UIFSA) 

Email address 

 

 

Reason for safeguarding contact 
information 

[  ] court or agency order  
[  ] protective order  
[  ] stalking injunction  

[  ] parentage order  
[  ] custody order (UCCJEA) 
[  ] support order (UIFSA) 

Email address 

laintiff/Petitioner or Defendant/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). 

Attorney or Licensed Paralegal Practitioner of record (if applicable) 

Signature ► 

Printed Name 

Signature ► 

Printed Name 

 

 

 

 

1053GEJ Approved April 16, 2018 / 
Revised December 20, 2021 

Non-public Information – Safeguarded Contact 
Information 

Page 2 of 2 

      P

   

 

 
Date 

 
Date 

       

 

 

 

 

 

 

 

 

Name 

Residential Address 

City, State, ZIP 

Phone 

Residential Address 

City, State, ZIP 

Phone 

ame 

  N