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CONFIDENTIAL

In the case of wanting to identify family members and social security numbers for spouses involved in a divorce case, the following form has to be completed and submitted.

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CONFIDENTIAL  
CON114  State  ENG  7/ 15    www.mncourts.gov/forms  Page 1 of 2 State of Minnesota       District Court  
County     Judicial District:    
    Court File Number:    
    Case Type:   Juvenile  
 
In the Matter of the Welfare of the Child(renyfRf :  
BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB  
  Parent (syf       /egal Custodian (syf  
  Confidential Information Form  
(Form 11.4yf  
Minn. 5. -uv. Prot. P. .4, subd. 5  
                
This  form  shall  not  be  accessible  to  the  public  except  by  court  order.    This  form  shall  be 
accessible  to  case  participants  as  authorized  by  the  court.    This  form  shall  be  accessible  to 
case  parties  unless  it  contains  information  in  sections  3  (identity  of  reporter  of  abuseyf  or  4 
(HIV-related  informationyf  in  which  case  it  shall  be  accessible  to  the  parties  as  authorized 
by the court.   
 
 
1.  Name, address, home, or location of any shelter care or foster care facility in which a 
c	

hild is placed under a court order. 
  Reference in 
Document   Name of 
Shelter/Foster Care 
Facility or Parent   Shelter/Foster Care Address   
  Child in 
Shelter/Foster 
Care  
Shelter  / Foster 
Parent 1    
     
Shelter / Foster 
Parent  2    
     
Shelter / Foster 
Parent  3    
     
 
 
2.  Information that identifies a child as a victim of an alleged or adjudicated sexual 
assau

lt. 
  Reference 
in 
document   Child’s First and Last Name   Child’s Date of Birth  
(mm /dd/yyyyyf  
Child 1      
Child 2      
Child 3      
Child 4

CONFIDENTIAL  
CON114  State  ENG  7/ 15    www.mncourts.gov/forms  Page 2 of 2 
3. 
Portions of juvenile protection case records that identify reporters of abuse or neglect 
  Reporter 1:                          
Reporter 2:                          
Reporter 3:                          
 
 
4. 
Information that a person has undergone HIV testing and/or HIV test results 
 
______________________________________________________________________________  
______________________________________________________________________________  
_______________________________________________________
_______________________ 
______________________________________________________________________________  
______________________________________________________________________________  
__________________________________________________________________________ ____ 
 
 
5.  Other information 	
that is confidential by statute, rule, or court order 
 
______________________________________________________________________________  
______________________________________________________________________________  
______________________________________________________________________________  
______________________________________________________________________________  
______________________________________________________________________________  
______________________________________________________________________________ 
 
   
 
Filed by:   
  Name:                       
Signed:                      
Attorney Reg. #: (if attorneyyf               
Firm/Agency Name
:                      Address:                       
City/State/Zip Code:                   
E-mail address :                   
Date:
Next: Certificate of Representation and Parties Previous: Consent to Entry of Decree
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