CIRCUIT COURT DISTRICT COURT OF MARYLAND FOR Located at Case No. Court Address vs. Plaintiff City/County Defendant REQUEST TO SHIELD INFORMATION IN A CASE RECORD (Rule 16-1009(b)(2)) In my judgment, the following information which consists of (i) a case record, (ii) part of a case record; or (iii) information contained in the case record, is confidential and not subject to inspection under the Court Access Rules. The information that should not be disclosed is (and you must be specific): The reason(s) the information should not be disclosed is (and you must be specific): Please answer the following questions that will assist the court in its decision: Have you ever made a request to shield? Yes No If "yes," was such previous request to shield before a clerk/custodian, Commissioner or a Judge? Yes No If applicable, indicate the name of the clerk/custodian, Commissioner or Judge and the approximate date the request was made: List what, if any, relationship you have to the record (e.g., filer of the record, subject of the record, witness cited in the record, etc.): CC-DC 52 (2/2008) Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com Case No. VERIFICATION I solemnly affirm under the penalties of perjury that the contents of this Request are true and correct to the best of my knowledge, information and belief. Signature Date ORDER/APPROVAL ORDERED/APPROVAL, this day of , 20 , by that the above Request to Shield is hereby GRANTED Date CC-DC 52(2/2008) DENIED. Signature Page 2 of 2 American LegalNet, Inc. www.FormsWorkFlow.com