Free NOTICE OF APPLICATION - Connecticut

NOTICE OF APPLICATION
JD-VS-3 (Page 1 of 2) Rev. 8/07 C.G.S. § 54-227

INSTRUCTIONS

STATE OF CONNECTICUT OFFICE OF VICTIM SERVICES JUDICIAL BRANCH www.jud.ct.gov

1. Complete and sign the form and have a witness (a Commissioner of the Superior Court or a Department of Correction Official) sign acknowledging that you have provided notice. 2. You must submit the original of this notice with any application to the Board of Pardons, Board of Parole or Department of Correction for release, other than a furlough, from a correctional institution. 3. You must submit the original of this notice with any application to the sentencing court or judge for a reduction in sentence, with any application to the review division for a review of sentence, with any application pursuant to C.G.S. § 51-251 for exemption from registration requirements of the Sex Offender Registry, or any application pursuant to C.G.S. § 54-255 to restrict or remove restrictions on the disclosure of Sex Offender Registry information. 4. Send a copy of this notice to the Office of Victim Services and to the Department of Correction - Victim Services Unit. 5. Retain a copy of this notice for your records.

TO: Office of Victim Services, 225 Spring St., Wethersfield, CT 06109 TO: Department of Correction - Victim Services Unit, 300 Sheldon St., Hartford, CT 06106
FROM (Name of Applicant) IN RE: (Name of Defendant) JD/GA COURT LOCATION WHERE APPLICATION FILED DEPARTMENT OF CORRECTION INMATE NUMBER (If known) DOCKET NO. DEFENDANT'S DATE OF BIRTH (If known)

NOTICE The undersigned states as follows: 1. I am the applicant referred to above. 2. The information set forth above is true and accurate and is made a part of this Notice as more fully set forth herein. 3. I have filed an application with the: ("X" one) Board of Pardons. Board of Parole. Department of Correction for release other than a furlough. Sentencing Court or Judge for a reduction in sentence. Sentence Review Division for a review of sentence. Court for exemption from sex offender requirements of section 54-251 of the Connecticut General Statutes. Court for an order restricting the dissemination of sex offender information pursuant to section 54-255 of the Connecticut General Statutes or removing such restriction. 4. I understand that, in accordance with section 54-227 of the Connecticut General Statutes, my application, as set forth in paragraph 3 above, can not be accepted unless I provide proof that I have given notice to the Office of Victim Services and to the Department of Correction - Victim Services Unit, at the above addresses, that I have filed the application. 5. I provided a copy of this Notice to the Office of Victim Services, 225 Spring St., Wethersfield, CT 06109, on the date and manner specified below;
DATE PROVIDED (Victim Services) "X" ONE SENT BY FIRST CLASS MAIL, POSTAGE PAID HAND DELIVERED OTHER (Specify)

and to the Department of Correction - Victim Services Unit, 300 Sheldon St., Hartford, CT 06106, on the date and in the manner specified below.
DATE PROVIDED (Dept. of Correction) "X" ONE SENT BY FIRST CLASS MAIL, POSTAGE PAID HAND DELIVERED OTHER (Specify)

The Judicial Branch of the State of Connecticut complies with the Americans with Disabilities Act (ADA). If you need a reasonable accommodation in accordance with the ADA, contact the Office of Victim Services at 1-800-822-8428.
SIGNED (Applicant) ON (Date)

X
WITNESS STATEMENT I acknowledge that the applicant noted above provided a copy of this Notice of Application to the Office of Victim Services and to the Department of Correction - Victim Services Unit in the manner specified above.
SIGNED (Commissioner of the Superior Court/Corrections Official) ON (Date) TITLE

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NOTICE OF APPLICATION
JD-VS-3 (Page 2 of 2) Rev. 8-07 C.G.S. § 54-227

STATE OF CONNECTICUT OFFICE OF VICTIM SERVICES JUDICIAL BRANCH www.jud.ct.gov TO BE COMPLETED BY THE APPLICANT

FROM (Name of Applicant) IN RE: (Name of Defendant)

JD/GA COURT LOCATION WHERE APPLICATION FILED DEPARTMENT OF CORRECTION INMATE NUMBER (If known)

DOCKET NO. DEFENDANT'S DATE OF BIRTH (If known)

FOR OVS USE ONLY OVS Compliance Requirement Certified letter mailed to registrant/victim at last known address. No registrant/victim on file.
SIGNED (OVS Staff) DATE SIGNED

FOR DOC USE ONLY DOC Compliance Requirement Certified letter mailed to registrant/victim at last known address. No registrant/victim on file.
SIGNED (DOC Staff) DATE SIGNED

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