REQUEST FOR NONDISCLOSURE OF INFORMATION IN PROTECTION ORDER REGISTRY JD-CL-80 Rev. 12-16 C.G.S. § 51-5c(c) STATE OF CONNECTICUT SUPERIOR COURT www.jud.ct.gov Instructions to Clerk 1. Enter this request into the Protection Order Registry in the "Additional Disclosure Restrictions" window by checking the box for "Protected Person has filed a Request for Nondisclosure of Information in the Protection Order Registry, JD-CL-80." 2. Refer to the Protection Order Registry Policy and Procedures Manual for more information, if necessary. 3. Keep the original for the court file, and send a copy to the Protection Order Registry unit of the Court Operations Division by e-mail at Justice.Support@jud.ct.gov, or by fax at (860) 610-0480. INFORMATION FOR PROTECTED PARTY 1. This form is used to ask the Protection Order Registry not to disclose (give out) your name and address, which is kept in the Protection Order Registry because you are protected by a protective or restraining order, to anyone except to the law enforcement agencies that are listed below. 2. Please note: Filing this form will keep the Protection Order Registry from giving out your information to anyone except the law enforcement agencies listed below, including other law enforcement agencies that may need this information if you make a routine call for assistance (help). 3. If you want to limit the law enforcement agencies that have access to your name and address from the Protection Order Registry, fill out this form, file the original with the clerk's office at the court where your protective order or restraining order was issued, and keep a copy for your records. 4. Please also note: Filing this form does not change whether or how the court can disclose any information about you that is in court files that are open to the public. 5. If you applied for an order for relief from abuse in the family court, and you believe (think) that the disclosure of the information about your location that is kept in the family court file would jeopardize (put at risk) you and/or your child or children's health, safety, or liberty (freedom), you can also file a "Request for Nondisclosure of Location Information," form JD-FM-188, with the clerk's office at the family court to ask the court to seal your location information in the family court file. Name of case Protected party's name (First, middle initial, last) Docket number Respondent's/Defendant's name (First, middle initial, last) I, the protected party listed above, ask that the Protection Order Registry NOT disclose my name and address except to the law enforcement agencies for: The town in which I reside (live): The town in which I am employed (work): The town in which the respondent/defendant resides (lives): Signed (Protected Party) Date signed 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. American LegalNet, Inc. www.FormsWorkFlow.com ADA NOTICE