STATE OF INDIANA	)
	) SS:
COUNTY OF DELAWARE	)

Petitioner

Respondent

IN THE DELAWARE CIRCUIT COURT NO.

CAUSE NO. 18

Notice of Exclusion of Confidential Information from Public Access

(FILED WITH TRIAL COURT CLERK for documents filed with the clerk)

(TENDERED IN OPEN COURT for documents tendered in open court)

Contemporaneous with the filing tender of this notice, Your Name

has filed tendered confidential information under the Indiana Rules on Access to Court

Records. Your Name , provides this notice that the confidential information is to

remain excluded from public access in accordance with the authority listed below:

Name or description of document

Income Withholding Order

ACR grounds for exclusion

Complete Social Security Number

ACR Rule 5(C)(1)

[NOTE: If Rule 5(A)(1or 3), 5 (B) (1 or 2), or 5 (D)(2) provides the basis for exclusion, you must also list the specific law, statute, or rule declaring the information confidential.]