This is a private record. 

Non-public Information –  
Parent Identification and Location  Case Number __________________________ 

Notice:  This information is required by the U.S. Secretary of Health and Human 
Services. If the information changes, you must complete and file another form. 
(Utah Code 62A-11-304.4.) 
This form is accessible only by the other party and any attorneys in the case. The form 
is not a public record. 

Name 

Residential address 

Phone number 

 

[  ]  Keep my 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, omit your residential address from this document and from all other papers filed 
with the court. Include it only on the Safeguarded Address form.) 

Mailing address (if different from residential address) 

Date of birth 

Social Security Number 

Driver's license 

State  Number 

Employer name, address and phone number 

Employer name, address and phone number 

I am: (check all that apply) 

[  ] Petitioner  [  ] Respondent    [  ] Custodial parent  [  ] Non-custodial parent 

Filing this information about    [  ] myself (required)    [  ] the other party (optional) 

 

1051GEJ Approved April 16, 2018 / 
Revised October 10, 2019 
 

Non-public Information – Parent Identification and 
Location 

Page 1 of 2 

Petitioner 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). 

Attorney or Licensed Paralegal Practitioner of record (if applicable) 

Signature ► 

Printed Name 

Signature ► 

Printed Name 

 

 

 

 

   

 
Date 

 
Date 

 

1051GEJ Approved April 16, 2018 / 
Revised October 10, 2019 
 

Non-public Information – Parent Identification and 
Location 

Page 2 of 2