Adopted Rule - 20090208

STATE OF NORTH DAKOTA, County of _______	) ) )	In District Court _______ Judicial District
___________,	)
Plaintiff	)
vs.	)	Case No. _____
____________,
Defendant	)	CONFIDENTIAL INFORMATION FORM	(Provided in Accordance With N.D.R.Ct. 3.4)

The information on this form is confidential and must not be placed in a publicly accessible portion of a file.

	NAME	SOCIAL SECURITY NUMBER, TAXPAYER IDENTIFICATION NUMBER, FINANCIAL ACCOUNT NUMBER, AND BIRTH DATE
Plaintiff	1. ______________	_________________________________
	2. ______________	_______________________________________
	3. ______________	_______________________________________
Defendant	1. ______________	_______________________________________
	2. ______________	_______________________________________
	3. ______________	_______________________________________
Other party	1. ______________	_______________________________________
(e.g. minor children)	2. ______________	_______________________________________

Information supplied by:
_________________________________________________
(print or type name of party submitting this form to the court)

Signed: _________________________________
Address: _________________________________
Phone Number: _________________________________
State Board of Law Examiners ID #: _________________________________
Date: _________________________________