CIRCUIT COURT Located at DISTRICT COURT OF MARYLAND FOR Court Address STATE OF MARYLAND City/County Case No. vs. Defendant TRACKING NUMBER(S) (Additional tracking numbers may be placed at the top of this page.) NOTICE OF REGISTRATION FOR COURT SUPERVISED REGISTRANTS (Maryland Code, Criminal Procedure Article (CP), §§ 11-701 to 11-721) As a convicted Tier I Sex Offender Tier II Sex Offender Tier III Sex Offender Sexually Violent Predator, you are subject to the requirements of CP § § 11-701 to 11-721, as follows: (1) INITIAL REGISTRATION: (A) Maryland Resident at Sentencing: At this time, a Tier I, Tier II, or Tier III Sex Offender, and/or Sexually Violent Predator must register with this Court, which is your supervisory authority because the Court is granting you probation other than under the supervision of the Division of Parole & Probation, a suspended sentence, or time served. To register, you must complete a registration statement, be photographed, fingerprinted, and have palm prints taken, all of which will be disseminated as required by law. If registrant has not submitted a DNA sample as defined in PS § 2-501, a DNA sample will be required. In addition, within 3 days after the registration mentioned above, a sex offender must register in person with local law enforcement unit designated by the County/Baltimore City in every county/city where you reside. Refer to the list of counties included with this form for your registration location. A local unit may require information in addition to that asked on the registration statement, such as a copy of your passport, immigration papers, Social Security number, vehicle and telephone information. (B) Non-Resident at Sentencing: A Tier I, Tier II, Tier III, and/or Sexually Violent Predator who does not live in Maryland at this time must register, in the manner set out in subsection (1)(A): l within 3 days after you move into the state of Maryland to reside or habitually live, whether temporary, permanent or if you have no fixed residence. l within 3 days after you begin employment in Maryland - defined in CP § 11-701 to include a full-time or part-time occupation, job or vocation whether compensated financially, volunteered, or done for educational or government benefit. l within 3 days after you register as a student in Maryland at an educational institution - defined in CP § 11-704(a)(7)(ii) to include a secondary school, institution of higher education, professional institution, or trade institution, whether private or public. Continued On Back CC-DC/CR 85 (Rev.10/2010) Page 1 of 4 American LegalNet, Inc. www.FormsWorkFlow.com Case No. vs. (2) PERIODIC REGISTRATION: (A) In addition to registration described in subsection (1), you must continue to register as follows: • Tier I Sex Offender: in person, every 6 months for 15 years with each local law enforcement unit designated by the County/Baltimore City where you reside. • Tier II Sex Offender: in person, every 6 months for 25 years with each local law enforcement unit designated by the County/Baltimore City where you reside. • Tier III Sex Offender: in person, every 3 months for life with each local law enforcement unit designated by the County/Baltimore City where you reside. • Sexually Violent Predator: in person every 3 months with a local law enforcement unit for the length of time determined by your designated Tier: 15 years for Tier I; 25 years for Tier II; and lifetime for Tier III. (3) CHANGE OF EDUCATIONAL STATUS: Within 3 days after enrolling or terminating enrollment as a full-time or part-time student at an institution of higher education in Maryland, or within 3 days of commencing or terminating employment at the institution of higher learning, you must a) provide notice in person to the local law enforcement unit where the institution of higher education is located and b) if you enroll in an institution in another state with a registration requirement, register in person with the law enforcement unit or Sex Offender Registration Unit designated by that state. (4) CHANGE OF EMPLOYMENT STATUS: Within 3 days after you begin employment in Maryland and within 3 days after you terminate employment, you must a) notify the local law enforcement unit where you most recently registered and each local law enforcement unit where you will reside or habitually live and b) if you become employed in another state with a registration requirement, register in person with the law enforcement unit or Sex Offender Registration Unit designated by that state. (5) CHANGE OF NAME: Within 3 days after a Court grants you a legal change of name, you must give notice of the change in writing to the local law enforcement unit where you reside or habitually live. (6) CHANGE OF RESIDENCE: Within 3 days after you change your residence or the county in which you habitually live, you must: a) give notice of the change in writing or in person to each local law enforcement unit where you reside or habitually live; and b) if your new address is in another state with a registration requirement, register with the law enforcement unit or Sex Offender Registration Unit designated by that state. (7) CHANGE OF RESIDENCE OUTSIDE THE UNITED STATES TO RESIDE, WORK, OR ATTEND SCHOOL: At least 3 days prior to leaving the United States to commence residence, employment, or attend school, you must: a) give notice either in writing or in person to each local law enforcement unit where you reside or habitually live and b) if your new address is in another country with a registration requirement, register with the law enforcement unit or Sex Offender Registration Unit designated by that country. (8) ABSENCE OF MORE THAN 7 DAYS / TEMPORARY RESIDENCE / ALTERED LOCATION OF RESIDENCE FOR MORE THAN 5 DAYS: Prior to obtaining a temporary residence, commencing the period of absence, or temporarily altering a location where you reside or habitually live, you must notify each law enforcement unit where you reside or habitually live in writing or in person and include (a) the temporary address or a detailed description of the temporary location where you will reside or habitually live (b) the anticipated dates that you will be absent from your permanent residence or the locations where you regularly reside or habitually live. (9) NEW ELECTRONIC MAIL ADDRESS, COMPUTER LOG-IN, SCREEN NAME, IDENTITY, INSTANT MESSAGE OR CHAT ROOM IDENTITY: Within 3 days after you establish or change your electronic information, you must give the State Registry written notice of the new information . Continued On Next Page CC-DC/CR 85 (Rev. 10/2010) Page 2 of 4 American LegalNet, Inc. www.FormsWorkFlow.com Case No. vs. (10) NEW HOME OR CELL PHONE NUMBERS: Within 3 days after you establish or change your home or cell phone number, you must notify the local law enforcement unit where you most recently registered and each local law enforcement unit where you will reside or habitually live. (11) CHANGE OF VEHICLE OR LICENSE PLATE INFORMATION: Within 3 days after you acquire or change your vehicle or license plate information, you must notify the local law enforcement unit where you most recently registered and each local law enforcement unit where you will reside or habitually live. (12) HOMELESS REGISTRANTS: Within 3 days of registering with the supervising authority and within 3 days after entering and remaining in a county, you must register in person with the law enforcement unit in each county where you habitually live and reregister once a week in person while habitually living in the county. Within 3 days after obtaining a permanent address, you must register with your supervising authority and each local law enforcement unit where you will reside. These registration requirements are in addition to any other requirements for your classification. (13) PENALTIES: Knowingly failing to register; knowingly failing to provide notice of a change of residence, county, educational status, employment, name, electronic identification information, vehicle or license plate information, home or cell phone numbers; knowingly fail to provide required information in a registration statement; or, knowingly providing false information of a material fact is a misdemeanor for which prosecution may be brought at any time and, on conviction, you can be imprisoned up to 3 years and/or fined up to $5,000; for a second or subsequent offense, is guilty of a felony and on conviction is subject to imprisonment not exceeding 5 years and/or fined up to $10,000. In addition, the conviction will be reported to the State Board of Election, disqualifying you to vote as provided by law. (14) DISSEMINATION OF DATA: In addition to any dissemination otherwise allowed by law, CP §§ 11-701 to 11-721 allow and, in some instances, require registration statements and/or data, fingerprints, palm prints, updated digital images, photographs, and verification forms be disseminated to the Federal Bureau of Investigation, the DPSCS, a county and/or campus municipal law enforcement unit, a law enforcement unit in another state, a school superintendent, a school principal(s), a victim(s), or a parent(s) or legal guardian(s), a witness(es), and members of the public. Date ACKNOWLEDGMENT I hereby acknowledge that this Court has explained to me the requirements of CP §§ 11-701 to 11-721 and that I have received a copy of this Notice. Signature of Defendant Defendant's Resident Address (street number, apt #, city state, zip code CC-DC/CR 85 (Rev. 10/2010) Page 3 of 4 American LegalNet, Inc. www.FormsWorkFlow.com REGISTRATION LOCATIONS You must register at the appropriate law enforcement agency. On this list, find Baltimore City/County where you live and report to the address shown for registration. ALLEGANY COUNTY Allegany County Police Department Combined County Investigative Unit Cumberland City Police Department 20 Bedford Street Cumberland, MD 21502 CHARLES COUNTY Charles County Sheriff's Office Crimes Against Dependent Persons 6845 Crain Highway LaPlata, MD 20646 PRINCE GEORGE'S COUNTY Prince George's County Police Department 7600 Barlow Road Landover, MD 20875 ANNE ARUNDEL COUNTY Anne Arundel County Police Department 8495 Veteran's Highway Millersville, MD 21108 DORCHESTER COUNTY Dorchester County Sheriff's Office 829 Fieldcrest Road Cambridge, MD 21613 QUEEN ANNE'S COUNTY Queen Anne's County Sheriff's Office 505 Railroad Avenue Centreville, MD 21617 BALTIMORE CITY Baltimore City Police Department CID/SORU 601 E. Fayette Street Baltimore, MD 21211-2908 FREDERICK COUNTY Frederick County Sheriff's Office 110 Airport Drive East Frederick, MD 21701 SOMERSET COUNTY Somerset County Sheriff's Office 30426A Sam Barnes Road Westover, MD 21871-3302 BALTIMORE COUNTY Baltimore County Police Department Sex Offender Registry Team 700 East Joppa Road Towson, MD 21286 GARRETT COUNTY Garrett County Sheriff's Office 311 E. Alder Street Oakland, MD 21550 ST. MARY'S COUNTY St. Mary's County Sheriff's Office 23150 Leonard Hall Drive Leonardtown, MD 20650 CALVERT COUNTY Calvert County Sheriff's Office 30 Church Street Prince Frederick, MD 20678 HARFORD COUNTY Harford County Sheriff's Office Sex Offense Unit 45 S. Main Street Bel Air, MD 21014 TALBOT COUNTY Talbot County Sheriff's Office 115 West Dover Street Easton, MD 21601 CAROLINE COUNTY Caroline County Sheriff's Office 101 Gay Street Denton, MD 21629 HOWARD COUNTY Howard County Police Department 3410 Courthouse Drive Ellicott City, MD 21043 WASHINGTON COUNTY Washington County Sheriff's Office 500 Western Maryland Parkway Hagerstown, MD 21740 CARROLL COUNTY Maryland State Police Westminster Barrack 1100 Baltimore Boulevard Westminster, MD 21157 KENT COUNTY Kent County Sheriff's Office Criminal Investigation Division 104 Vickers Drive, Unit B Chestertown, MD 21620 WICOMICO COUNTY Wicomico County Sheriff's Office 401 Naylor Mill Rd. Salisbury, MD 21804 CECIL COUNTY Cecil County Sheriff's Office Upper Chesapeake Corporate Center 107 Chesapeake Boulevard, Suite 112 Elkton, MD 21921 MONTGOMERY COUNTY Montgomery County Police Department Records and technology Division 7300 Calhoun Place, Suite 300 Rockville, MD 20855 WORCESTER COUNTY Worcester County Sheriff's Office 1 West Market Street, Room 1001 Snow Hill, MD 21863 Sex Offender Registry Unit, P.O. Box 32706, Pikesville, MD 21282-2708 Updated 4/12/07 CC-DC/CR 85 (Rev. 10/2010) Page 4 of 4 American LegalNet, Inc. www.FormsWorkFlow.com