Policy Manual
COURTS
Superior Court For Juvenile Matters

Attachment to 46-3-10

IN RE: [Child’s name & D.O.B.]                  SUPERIOR COURT FOR JUVENILE MATTERS

DATE                                                  AT [LOCATION OF COURT]      

REQUEST FOR NONDISCLOSURE OF LOCATION INFORMATION 

                 Pursuant to Public Act 00-191, the petitioner respectfully requests that the address of  the respondent [name] not be disclosed to anyone, including the parties to this case and that this information be sealed.   

I, [Name of  Social Worker], am the assigned social worker for this case.  I believe that the health, safety or liberty of [name of respondent] will be jeopardized by disclosure of that information.   

The confidential address of [name of respondent] is: 

                                    or 

[Name of respondent] has provided me with the following mailing address in order to receive future notices.   

                                    or

                 I hereby certify that the foregoing statements are true to the best of my knowledge, information and belief.

                                                _______________________________  

[Social Work's Name]

Social Worker          

               Department of Children and Families

Subscribed and sworn to before me this     day of                , 200 .

____________________________      _______________________________

Notary/Comm. Superior Court               My Commission Expires