REQUEST FOR NONDISCLOSURE OF LOCATION INFORMATION JD-FM-188 Rev. 4-15 C.G.S. § 46b-115s (e) STATE OF CONNECTICUT SUPERIOR COURT www.jud.ct.gov Instructions To Clerk 1. Seal any location information except disclosable mailing address. 2. Do not disclose the location information to the public, including anyone involved in the case, except by order of the court after hearing. Court Use Only REQNON *REQNON* 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 a court clerk or an ADA contact person listed at www.jud.ct.gov/ADA. Docket number (If known) Instructions To Party 1. Complete the information below if you believe that disclosure of location information would jeopardize you and/or your child(ren)'s health, safety or liberty. 2. You must swear that your statement is true and sign it in front of a court clerk, a notary public or an attorney who will also sign and date it. 3. Keep a copy for your records. 4. Do not file anything further with the court containing location information other than to report a change in your mailing address. Name of Case Plaintiff's name (First, middle initial, last) ADA NOTICE Defendant's name (First, middle initial, last) 1. I, the above-named (check one) myself my child(ren) plaintiff (Specify name(s)) defendant believe that the health, safety or liberty of (check one or both) would be jeopardized by disclosure of location information. I therefore request that no location information contained in this case pertaining to (check one or both) myself 2. (check one) Attorney's name (First, middle initial, last) my child(ren) be disclosed to anyone including parties to this case and that this information be sealed. I have an attorney representing me in this case. My attorney is: I do not have an attorney representing me in this case. Therefore, I am providing my mailing address below. I understand that this address will be public information. Full Mailing Address (Public Information) 3. (check one) There have been no documents previously filed with the court that contain location information that poses the risk. There is location information posing the risk contained in documents previously filed with the court. The location information can be found in the following documents (Attach additional sheet if necessary). (Do not indicate what the location information is.) NOTICE TO APPLICANT: DO NOT FILE ANY PAPERWORK WITH THE COURT THAT CONTAINS ANY LOCATION INFORMATION IN ANY FURTHER PLEADINGS OTHER THAN TO REPORT A CHANGE IN YOUR MAILING ADDRESS. I hereby certify that the foregoing statements are true to the best of my knowledge and belief Signature Print name of person signing Date signed Subscribed and sworn to before me (Assistant Clerk, Commissioner of Superior Court, Notary Public) Distribution: Original -- For the Court Copy -- For your records American LegalNet, Inc. www.FormsWorkFlow.com