PLAINTIFF CONFIDENTIAL INFORMATION FORM G.L. c. 209A, § 8 or G.L. c. 258E, § 10 PLAINTIFFʼS NAME DOCKET NO. (for court use only) Massachusetts Trial Court This form should be sealed in an envelope marked “PLAINTIFFʼS ADDRESS – CONFIDENTIAL”. DATE OF BIRTH PLAINTIFFʼS RESIDENTIAL ADDRESS PLAINTIFF’S RESIDENTIAL TELEPHONE NO. If this is an apartment building or other multiple family dwelling, check here ANY FORMER ADDRESS PLAINTIFF HAS LEFT TO AVOID ABUSE (for G.L. c. 209A abuse prevention cases only) NAME OF PLAINTIFF’S WORKPLACE ADDRESS OF PLAINTIFF’S WORKPLACE PLAINTIFF’S WORKPLACE TELEPHONE NO. NAME OF PLAINTIFF’S SCHOOL ADDRESS OF PLAINTIFF’S SCHOOL PERSONS AUTHORIZED BY PLAINTIFF TO HAVE ACCESS TO THIS CONFIDENTIAL INFORMATION DATE SIGNED PLAINTIFF’S SIGNATURE x THIS FORM IS CONFIDENTIAL AND IS NOT AVAILABLE TO THE PUBLIC, THE DEFENDANT OR THE DEFENDANT’S ATTORNEY. Except with a judge’s permission, this form is available only to you, to your attorney, to those you authorize to have access (see above), and to certain persons when access is necessary in the performance of their duties (prosecutors, law enforcement officers, victim-witness advocates, sexual assault counselors and, in G.L. c. 209A cases, domestic violence counselors). IF A JUDGE ORDERS THE DEFENDANT TO REMAIN AWAY FROM YOUR RESIDENCE, WORKPLACE OR SCHOOL, THOSE ADDRESSES WILL APPEAR IN THE COURT ORDER. THEY WILL NOT BE AVAILABLE TO THE PUBLIC BUT THEY WILL BE DISCLOSED TO THE DEFENDANT. If you do not want those addresses to appear in the court Order and thereby be disclosed to the Defendant, you should specifically request that they be omitted from the court Order. If you and the Defendant are both over 18, court records of this matter will generally be open to public inspection. If you have good reasons to ask a judge to keep other parts of the court record from public inspection, ask the Clerk’s or Register’s Office to explain how to file a Motion for Impoundment under Trial Court Uniform Rule VIII on Impoundment Procedure. You may also file a Motion for Impoundment if you have good reasons why your addresses or other confidential information in this case should not be disclosed to those who would otherwise have access in the course of their duties (prosecutors, law enforcement officers, victim-witness advocates, sexual assault counselors and, in G.L. c. 209A cases, domestic violence counselors). Usually, a general preference for privacy is not alone a sufficient reason for a judge to impound court records from public inspection. If either you or the Defendant is under 18, other court records of this matter will not be open to public inspection, and will be available only to you and the Defendant, and to your attorneys. They will also be available to the parent or guardian of any party who is under 18. FA/HA-6 (1/12) American LegalNet, Inc. www.FormsWorkFlow.com