IN THE DISTRICT SUPERIOR COURT FOR THE STATE OF ALASKA
AT
In the matter of:
)
)
)
,
)
CASE NO.
A minor under 18 years of age.
)
REQUEST TO KEEP IDENTIFYING
)
INFORMATION CONFIDENTIAL IN
Date of birth:
)
TRIBAL COURT ICWA ORDER
)
I ask the state court not to disclose identifying information about the following person or
persons, and to keep the information confidential or sealed:
child named above
person awarded custody or visitation named
I certify under penalty of perjury that the health, safety, or liberty of the person(s) above will
be jeopardized by disclosing identifying information because:
SIGNATURE AND NOTARY
I certify under penalty of perjury that the information in this document is true.
Print Name
Signature
(sign in front of the notary or court clerk)
Subscribed and sworn to or affirmed before me at
, Alaska on
(SEAL)
Clerk of Court, Notary Public or other person
authorized to administer oaths.
My commission expires
CERTIFICATION (
)
IF NO NOTARY AVAILABLE
I certify under penalty of perjury that the information in this document is true, and a notary or
other official empowered to administer oaths is not available to administer an oath.
Date
Signature
Place (city or village)
Print Name
CN-625 (3/15)(cs)
25 USC §§ 1901-1963;
REQUEST TO KEEP IDENTIFYING INFORMATION CONFIDENTIAL
CINA Rules 24-25; AS 09.63.020
IN THE DISTRICT SUPERIOR COURT FOR THE STATE OF ALASKA
AT
In the matter of:
)
)
)
,
)
CASE NO.
A minor under 18 years of age.
)
REQUEST TO KEEP IDENTIFYING
)
INFORMATION CONFIDENTIAL IN
Date of birth:
)
TRIBAL COURT ICWA ORDER
)
I ask the state court not to disclose identifying information about the following person or
persons, and to keep the information confidential or sealed:
child named above
person awarded custody or visitation named
I certify under penalty of perjury that the health, safety, or liberty of the person(s) above will
be jeopardized by disclosing identifying information because:
SIGNATURE AND NOTARY
I certify under penalty of perjury that the information in this document is true.
Print Name
Signature
(sign in front of the notary or court clerk)
Subscribed and sworn to or affirmed before me at
, Alaska on
(SEAL)
Clerk of Court, Notary Public or other person
authorized to administer oaths.
My commission expires
CERTIFICATION (
)
IF NO NOTARY AVAILABLE
I certify under penalty of perjury that the information in this document is true, and a notary or
other official empowered to administer oaths is not available to administer an oath.
Date
Signature
Place (city or village)
Print Name
CN-625 (3/15)(cs)
25 USC §§ 1901-1963;
REQUEST TO KEEP IDENTIFYING INFORMATION CONFIDENTIAL
CINA Rules 24-25; AS 09.63.020
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