NOTICE OF APPLICATION JD-VS-3 (Page 1 of 2) C.G.S. § 54-227 Rev. 7-16 ADA Notice 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. STATE OF CONNECTICUT OFFICE OF VICTIM SERVICES JUDICIAL BRANCH www.jud.ct.gov Instructions 1. You must fill out this form and have a Commissioner of the Superior Court or a Department of Correction (DOC) official sign the form acknowledging that you have provided a copy of this form to the Office of Victim Services (OVS) and DOC Victim Services Unit. 2. Send the original form with the application that you file with the Superior Court, Board of Pardons and Paroles, or DOC. 3. Keep a copy of this form for your records. To: Office of Victim Services, 225 Spring Street, 4th Floor, Wethersfield, CT 06109 To: Department of Correction - Victim Services Unit, 24 Wolcott Hill Road, Wethersfield, CT 06109 Name of person completing form (Applicant) Name of inmate/defendant JD/GA court location where application is filed Department of Correction inmate number (If known) Docket number Inmate/defendant's date of birth (If known) Please check the box that describes the application to be filed. If you check more than one box, this form will be returned to you. You MUST complete a Notice of Application form for each application you file. Board of Pardons and Paroles: for parole - Parole Unit for clemency by current offender - Pardons Unit Department of Correction for release other than a furlough Superior Court for sentence modification, motion and order for review of sentence to restrict or to remove restriction on dissemination of sex offender registration information for exemption from the sex offender registration requirements By signing this application, I am stating that I am the person completing this form and the information in this Notice of Application is true and accurate. I understand that the application will not be accepted unless I provide proof that I have given a copy of this application to the Office of Victim Services and to the Department of Correction - Victim Services Unit at the addresses listed above and on the date and in the way listed below: Date provided to Office of Victim Services Please check one box: Sent by first class mail, postage paid Hand delivered Other (Specify) Date provided to Department of Correction Please check one box: Sent by first class mail, postage paid Hand delivered Other (Specify) Signed (Applicant) On (Date) 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 way specified above. Signed (Commissioner of the Superior Court/Corrections Official) On (Date) Title American LegalNet, Inc. www.FormsWorkFlow.com NOTICE OF APPLICATION JD-VS-3 (Page 2 of 2) Rev. 7-16 C.G.S. § 54-227 STATE OF CONNECTICUT OFFICE OF VICTIM SERVICES JUDICIAL BRANCH www.jud.ct.gov To Be Completed By The Applicant Name of person completing form (Applicant) Name of inmate/defendant JD/GA Court location where application filed Department of Correction inmate number (If known) Docket number Inmate/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 American LegalNet, Inc. www.FormsWorkFlow.com