THE STATE OF NEW HAMPSHIRE JUDICIAL BRANCH http://www.courts.state.nh.us Court Name: Case Name: Case Number: (if known) NOTICE OF INTENT TO DISCLOSE DEL/CHINS COURT RECORDS Delinquency CHINS Pursuant to RSA 169-B:22, IV(b) or RSA 169-D:18, IV(b), The (School District) intends to disclose the juvenile court records of the above-mentioned matter to a Department of Education hearing officer for a hearing scheduled on (date) I certify that on this date I provided a copy of this document to the parties listed below in the court proceeding and the due process hearing by: Hand-delivery OR US Mail OR E-mail (E-mail only by prior agreement of the parties based on Circuit Court Administrative Order). Date Authorized School District Representative NHJB-2440-DF (03/25/2013) American LegalNet, Inc. www.FormsWorkFlow.com Case Name: Case Number: NOTICE OF INTENT TO DISCLOSE DEL/CHINS COURT RECORDS Persons subject to juvenile proceedings have important rights to the confidentiality of juvenile court proceedings. This notice requests the disclosure of some or all of that information. If you object to the disclosure of information, you must file a written objection with the court no later than 10 days after the filing of the school district's notice. If you fail to object in writing, the court may allow private information to be revealed to the New Hampshire Department of Education hearing officer. NHJB-2440-DF (03/25/2013) American LegalNet, Inc. www.FormsWorkFlow.com