APPLICATION FOR EXEMPTION FROM SEX OFFENDER REGISTRATION REQUIREMENTS JD-CR-122 Rev. 5-16 C.G.S. §§ 53a-71, 53a-73, 53a-189, 54-251 CONNECTICUT JUDICIAL BRANCH SUPERIOR COURT www.jud.ct.gov INSTRUCTIONS TO CLERK 1. Do not accept this Application if the Applicant fails to also submit a completed JD-VS-3, Notice of Application. 2. Get original court file and schedule application for hearing. 3. Give notice to prosecutor and applicant. 4. If application is granted, send copy to Department of Public Safety and to the agency having custody of the offender (DOC if incarcerated, PSRB if committed, CSSD if probation), if any. DATE OF BIRTH DOCKET NO. INSTRUCTIONS TO APPLICANT 1. Complete this form with information for the case in which you were convicted or found not guilty by reason of mental disease or defect and for which you are asking for an exemption from the duty to register as a sex offender. 2. File the original and 1 copy with the clerk of court. 3. Forward a copy to the prosecuting attorney for the offense for which you are seeking to be released from the obligation to register. 4. You must also complete and attach form JD-VS-3, Notice of Application. TO: The Superior Court of the State of Connecticut FROM (Name of Applicant) ADDRESS OF APPLICANT (Number, Street, Town, and Apt. No ) DATE SENTENCED COURT SENTENCED AT (J.D. or G.A ) ADDRESS OF SENTENCING COURT (Number, street, and town) I, the Applicant signing below, ask the court to exempt me from the sex offender registration requirements of section 54-251 of the Connecticut General Statutes because: 1. I was convicted or found not guilty by reason of mental disease or defect of: ("X" one) Sexual assault in the 2nd degree under section 53a-71(a)(1) of the Connecticut General Statutes (for engaging in sexual intercourse with another person who was 13 or older but under 16 and I was more than three years older than that person) and I was less than 19 years old at the time of the offense. OR Sexual assault in the 4th degree under section 53a-73a(a)(2) of the Connecticut General Statutes (for subjecting another person to sexual contact without that person's consent). OR Voyeurism under section 53a-189a(a)(2) of the Connecticut General Statutes (for knowingly photographing, filming, videotaping, or otherwise recording the image of another person (A) without that person's knowledge and consent; (B) while that person was not in plain view; and (C) under circumstances where that person had a reasonable expectation of privacy, with the intent to arouse or satisfy my sexual desire). OR Voyeurism under section 53a-189a(a)(3) of the Connecticut General Statutes (for committing simple trespass and observing another person in other than a casual or cursory manner (A) without that person's knowledge or consent, and (B) while that person was inside a dwelling and not in plain view, and (C) under circumstances where that person had a reasonable expectation of privacy, with the intent to arouse or satisfy my sexual desire). OR Voyeurism under section 53a-189a(a)(4) of the Connecticut General Statutes (for knowingly photographing, filming, videotaping or otherwise recording the genitals, pubic area, or buttocks of another person, (A) without that person's knowledge and consent, and (B) while that person's genitals, pubic area, buttocks, undergarments, or stockings were not in plain view, with the intent to arouse or satisfy my sexual desire, or to arouse or satisfy the sexual desire of any other person) 2. I was released into the community, on or after October 1, 1998 with respect to this offense. 3. Registration is not required for public safety because of the following reason(s) (specify): 4. I have notified the Office of Victim Services and the Victim Services Unit within the Department of Correction of this application. A completed form JD-VS-3, Notice of Application, is attached to this application as proof of notice to the Office of Victim Services and to the Victim Services Unit within the Department of Correction. I have read the information above and understand it. I agree with these statements. CONSENTED TO BY (Parent or Guardian) SIGNED (Applicant) X DATE SIGNED DATE SIGNED SIGNED (Attorney for Applicant) ORDER OF COURT The application is DENIED. The Court, having found that registration is not required for public safety and, if the Applicant was convicted of a violation of section 53a-71(a)(1) of the Connecticut General Statutes, that the Applicant was under the age of nineteen at the time of the offense, GRANTS the application and the Applicant is exempted from the registration requirements of section 54-251 of the Connecticut General Statutes. SIGNED (Judge, Assistant Clerk) DATE SIGNED American LegalNet, Inc. www.FormsWorkFlow.com