FORM DC-301 MASTER 07/18 REQUEST FOR CONFIDENTIALITY Case No. ...................................................................................... Commonwealth of Virginia Va. Code 247247 19.2-11.01; 19.2-11.2 [ ] Circuit Court [ ] General District Court TO: .......................................................................................................................... [ ] Juvenile and Domestic Relations District Court Commonwealth of Virginia v. .................................................................................................................................................................................................... Requested by: ........................................................................................................................................................................................................................................NAME ........................................................................................................................................................................................................................................................................ ADDRESS (OPTIONAL) ........................................................................................................................................................................................................................................................................ EMPLOYER NAME AND ADDRESS (OPTIONAL) ........................................................................................................................................................................................................................................................................ TELEPHONE NUMBER (OPTIONAL) VIRGINIA DRIVER222S LICENSE NUMBER (OPTIONAL) I, the undersigned, am a [ ] victim [ ] spouse or child of a victim [ ] parent or legal guardian of a victim who is a minor or [ ] spouse, parent, sibling or legal guardian of a victim who is physically or mentally incapacitated, or who was the victim of a homicide. The crime committed against the victim was [ ] a felony [ ] one of the following: [ ] sexual battery in violation of Va. Code 247 18.2-67.4 [ ] assault and battery in violation of Va. Code 247 18.2-57 or 247 18.2-57.2 [ ] stalking in violation of Va. Code 247 18.2-60.3 [ ] attempted sexual battery in violation of Va. Code 247 18.2-67.5 [ ] driving while intoxicated in violation of Va. Code 247 18.2-266 [ ] maiming while driving intoxicated in violation of Va. Code 247 18.2-51.4 [ ] a violation of a protective order in violation of Va. Code 247 16.1-253.2 or 247 18.2-60.4 [ ] a delinquent act that would be a felony or a misdemeanor violation of one of the above offenses if committed by an adult [ ] witness in a criminal prosecution under Va. Code 247 18.2-46.2, 247 18.2-46.3 or 247 18.2-248, or of any violent felony as defined by 247 17.1-805(C). I request that the above-named court(s) not disclose, release or allow to be examined any information as to my residential address, telephone numbers, email addresses and place of employment or that of my family members except as specifically authorized by Va. Code 247 19.2-11.2. The names of my family members to whom this request applies are: ........................................................................................................................................................................................................................................................................ ................................................................................................ DATE OF REQUEST SIGNATURE OF PARTY MAKING REQUEST Received on ...........................................................by DATE AND TIME [ ] CLERK/DEPUTY CLERK [ ] MAGISTRATE [ ] INTAKE OFFICER TO THE CLERK: PLACE IN A SEALED ENVELOPE American LegalNet, Inc. www.FormsWorkFlow.com