CIRCUIT COURT DISTRICT COURT OF MARYLAND FORLocated at Case No.Court AddressCity/CountySTATE OF MARYLANDvs.DefendantCONFIDENTIAL SUPPLEMENT(Request for Shielding of Information in Criminal Case)Victim Requests Shielding Complainant Requests Shielding Witness Requests ShieldingDue to:Threats to Safety Made by Defendant or Person(s) on Defendant's BehalfAct of Violence by Defendant or Person(s) on Defendant's BehalfOtherVictim/Complainant/Witness (Please print.)AddressTelephone NumberI solemnly affirm that the contents of this Confidential Supplement request are true to the best of myknowledge, information, and belief.DateVictim/Complainant/Witness SignatureApprovedDeniedCC-DC-CR-001S (Rev. 10/2017)NOTICE: Remote access to the name, address, telephone number, date of birth, e-mail address andplace of employment of a victim or non-party witness is blocked. (Md. Rule 16-910)Commissioner/JudgeI.D. NumberShielding Not RequiredDateCity, State, ZipVictim/Complainant/Witness (Please print.)AddressTelephone NumberCity, State, ZipVictim/Complainant/Witness (Please print.)AddressTelephone NumberCity, State, ZipVictim/Complainant/Witness (Please print.)AddressTelephone NumberCity, State, Zip American LegalNet, Inc. www.FormsWorkFlow.com