FORM DC-301 MASTER 07/18
REQUEST FOR CONFIDENTIALITY Case No. ......................................................................................
Commonwealth of Virginia Va. Code §§ 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 b
y:
........................................................................................................................................................................................................................................
NAME
........................................................................................................................................................................................................................................................................
ADDRE
SS (OPTIONAL)
........................................................................................................................................................................................................................................................................
EMP
LOYER NAME AND ADDRESS (OPTIONAL)
........................................................................................................................................................................................................................................................................
TEL
EPHONE NUMBER (OPTIONAL) VIRGINIA DRIVER’S 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 § 18.2-67.4
[ ] assault and battery in violation of Va. Code § 18.2-57 or § 18.2-57.2
[ ] stalking in violation of Va. Code § 18.2-60.3
[ ] attempted sexual battery in violation of Va. Code § 18.2-67.5
[ ] driving while intoxicated in violation of Va. Code § 18.2-266
[ ] maiming while driving intoxicated in violation of Va. Code § 18.2-51.4
[ ] a violation of a protective order in violation of Va. Code § 16.1-253.2 or § 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 § 18.2-46.2, § 18.2-46.3 or § 18.2-248, or of any violent
felony as defined by § 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 § 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
