Divorce 4 – Confidential Info		
	Do not serve this form on Amielia. 
It is confidential.	
FL All Family 001: Confidential Information	
Quick Instructions:	
	1.	Review the form. Make changes if needed.	
	2.	Date and sign at the end.	
	3.	Make 1 copy for yourself. 
(Take off this page first!)	
	4.	File the original with the court clerk. Stamp your copy with the case number and date filed.	

Confidential Information (CIF)
Clerk:  Do not file in a public access file
Superior Court of Washington
County: Wahkiakum	
Case No.: 		 	
Important!  Only court staff and some state agencies may see this form.  The other party and their lawyer may not see this form unless a court order allows it.  State agencies may disclose the information in this form according to their own rules.
1. 	Who is completing this form?  (Name):  Shane-Michael T. Renecker	
2. 	Is there a current restraining or protection order involving the parties or children?   [X] No 
[  ] Yes.  If yes, who does the order protect? (Name/s): 	
3. 	Does your address information need to be confidential to protect your or your children’s health, safety, or liberty?  (Check one):   [ ] Yes  [X] No
If yes, explain why?  	
4. 	Your Information – This person is a (check one): [X] Petitioner   [  ] Respondent
Interpreter needed?  [X] No   [  ] Yes, language: 	
Full name (first, middle, last): 
Shane-Michael T. Renecker	Date of birth (MM/DD/YYY):
07/12/1972	Sex:
Male	
Driver’s license/Identicard (No., state):
	Race: 
White	Relationship to children in this case:
	
Mailing address (This address will not be kept private.) (street address or P.O. box, city, state zip): 
PMB 5280 PO Box 257, Olympia WA 98507	
Email:  Justthtaguy@gmail.com	Phone:  (425) 835-2589	
If your case is only about a protection order, skip to section 5.
Home address (check one):  [X] same as mailing address  [  ] listed below (street, city, state, zip):
 	
Social Sec. No: 		
Employer’s name: 	Employer’s phone: 	
Employer’s address: 	
5. 	Other Party’s Information – This person is a (check one):   [  ] Petitioner   [X] Respondent
Interpreter needed?  [X] No   [  ] Yes , language: 	
Full name (first, middle, last):
Amielia Elizabeth Renecker	Date of birth: (MM/DD/YYYY)
03/31/1982	Sex:
Female	
Driver’s license/Identicard (No., state):
	Race: 
White	Relationship to children in this case:
	
Mailing address (This address will not be kept private.) (street address or PO box, city, state zip):
1619 Scammell Ave NW Olympia WA 98502	
Email:  Amieliagorman@gmail.com	Phone:  (360) 474-7132	
If your case is only about a protection order, skip to section 6.
Home address (check one):  [  ] same as mailing address  [  ] listed below (street, city, state, zip):  
 	
Social Sec. No.: 		
Employer’s name: 	Employer’s phone: 	
Employer’s address: 	

•	Skip sections 6 – 9 if your case does not involve children.  Sign at the end.
6. 	Children’s Information  (You do not have to fill out the children’s Social Security numbers if your case is only about a protection order.)    
Child’s full name 
(first, middle, last)	Date of birth (mm/dd/yyyy)	Race	Sex	Soc. Sec. No.	Current location: lives with 	
1. 							
2.							
3.							
4.							
7. 	Have the children lived with anyone other than you or the other party during the last five years?  (Check one):  [  ] No  [  ] Yes         If yes, fill out below: 
Children lived with (name) 	That person’s current address	
1.		
2.		
8. 	Do other people (not parents) have custody or visitation rights to the children?  
(Check one):  [  ] No  [  ] Yes        If yes, fill out below:
Person with rights (name)		That person’s current address	
1.			
2.		
9. 	If you are asking for custody and are not the parent, list all other adults living in your home:
1.  (Name): 	Date of birth (mm/dd/yyyy):	
2.  (Name): 	Date of birth (mm/dd/yyyy):	
I declare under penalty of perjury under Washington State law that the information on this form about me is true.  The information about the other party is the best information I have or is unavailable because (explain):  	
[  ]	Check here if you need more space to list other Petitioners, Respondents, or children. Put that information on the Attachment to Confidential Information, form FL All Family 002, and attach it to this form.
Signed at (city and state): 		Date: 	
		Shane-Michael T. Renecker	
Petitioner/Respondent signs here		Print name here