CIRCUIT COURT DISTRICT COURT OF MARYLAND FOR Located at Court Address vs. Petitioner City/County Case No. Respondent REQUEST TO SHIELD PROTECTIVE ORDER RECORDS (FL § 4-512) 1. On , a Petition from Domestic Violence was Denied or Date Dismissed at the Interim Temporary Final stage of a proceeding and at least three (3) years have passed since the date of the denial or dismissal or a General Waiver and Release is attached. 2. A Final Protective Order or Peace Order has not been previously issued against the Respondent in any proceeding between this Petitioner and Respondent. 3. There are no protective orders or peace orders pending against the Respondent in a proceeding between this Petitioner and Respondent. 4. There are no criminal charges pending against this Respondent arising from alleged abuse against this Petitioner, described in the Annotated Code of Maryland, Family Law Article, § 4-512. 5. I request that the Court schedule a hearing and after the hearing order the shielding of all court records relating to the proceeding. I solemnly affirm under the penalties of perjury that the contents of this Request are true to the best of my knowledge, information and belief. Date Respondent Signature Address City, State, Zip Telephone Number CERTIFICATE OF SERVICE I hereby certify that on the day of Month , Year , I mailed a copy of this Petition to: Name and Address Name and Address Date Signature OR I have filed the attached Motion for Appropriate Relief. Date CC-DC/DV 21 (Rev. 10/2011) Signature American LegalNet, Inc. www.FormsWorkFlow.com