CIRCUIT COURT

DISTRICT COURT OF MARYLAND FOR

City/County

Located at STATE OF MARYLAND

Court Address

Case No.

vs.
Defendant

CONFIDENTIAL SUPPLEMENT
(Request for Shielding of Information) Victim Requests Shielding Due to: Complainant Requests Shielding Witness Requests Shielding

Threats to Safety Made by Defendant or Person(s) on Defendant's Behalf Act of Violence by Defendant or Person(s) on Defendant's Behalf Other

Victim/Complainant/Witness (Please print.)

Victim/Complainant/Witness (Please print.)

Address

Address

Telephone Number

Telephone Number

Victim/Complainant/Witness (Please print.)

Victim/Complainant/Witness (Please print.)

Address

Address

Telephone Number

Telephone Number

I solemnly affirm that the contents of this confidential supplement request are true to the best of my knowledge, information, and belief.

Date

Victim/Complainant/Witness Signature

Approved

Denied

Shielding Not Requested

Commissioner/Judge

I.D. No.

Date

NOTICE: Remote access to the name, address, telephone number, date of birth, e-mail address and place of employment of a victim or non-party witness is blocked. (Md Rule § 16-1008 (a)(3)(B))
CC-DC/CR 1S (Rev. 3/2008)

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