Delaware Cnty. C.P. CommonPleasAdminOrders_AOD THIS 28

ANGELA MARTINEZ ESQ., DIRECTOR

OFFICE OF SUPPORT

Kevin F. Kelly P.J.

EXHIBIT "A"

CONFIDENTIAL

INFORMATION

FORM

Policy of the Unified Judicial System of PennsylvaniaCase Records Public Access

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 thedisposition 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: References in Filing:

(full name of adult)

OR

This information pertains to a

minor with the initials of

and the full name of

(full name of minor)

and date of birth:

Social Security Number (SSN):

Financial Account Number (FAN):

Driver's License Number (DLN):

State of Issuance:

State Identification Number (SID):

Alternative Reference: