Court Use Only
1. I, the above-named (check one)
REQUEST FOR NONDISCLOSURE
OF LOCATION INFORMATION
STATE OF CONNECTICUT
SUPERIOR COURT
www.jud.ct.gov
I hereby certify that the foregoing statements are
true to the best of my knowledge and belief
Signature
Subscribed and sworn to before me (Assistant Clerk, Commissioner of Superior Court, Notary Public)
Instructions To Party
1. Complete the information below if you believe that disclosure of
location information would jeopardize you and/or your child(ren)'s
health, safety or liberty.
2. You must swear that your statement is true and sign it in front of a
court clerk, a notary public or an attorney who will also sign and date it.
3. Keep a copy for your records.
4. Do not file anything further with the court containing location
information other than to report a change in your mailing address.
JD-FM-188 Rev. 4-15
C.G.S. § 46b-115s (e)
1. Seal any location information except
disclosable mailing address.
2. Do not disclose the location
information to the public, including
anyone involved in the case, except
by order of the court after hearing.
Instructions To Clerk
(Specify name(s))
would be jeopardized by disclosure of location information. I therefore request that no location information contained in this
case pertaining to (check one or both)
Full Mailing Address
(Public Information)
Distribution: Original — For the Court Copy — For your records
NOTICE TO APPLICANT:
DO NOT FILE ANY PAPERWORK WITH THE COURT THAT CONTAINS ANY LOCATION INFORMATION
IN ANY FURTHER PLEADINGS OTHER THAN TO REPORT A CHANGE IN YOUR MAILING ADDRESS.
be disclosed to anyone including parties to this case and that this information be sealed.
2. (check one)
I understand that this address will be public information.
3. (check one)
information can be found in the following documents (Attach additional sheet if necessary).
(Do not indicate what the location information is.)
Name of Case
Docket number (If known)
Plaintiff's name (First, middle initial, last) Defendant's name (First, middle initial, last)
plaintiff defendant believe that the health, safety or liberty of (check one or both)
myself my child(ren)
myself my child(ren)
I have an attorney representing me in this case. My attorney is:
Attorney's name (First, middle initial, last)
I do not have an attorney representing me in this case. Therefore, I am providing my mailing address below.
There have been no documents previously filed with the court that contain location information that poses the risk.
There is location information posing the risk contained in documents previously filed with the court. The location
Print name of person signing
Date signed
*REQNON*
REQNON
ADA NOTICE
The Judicial Branch of the State of
Connecticut complies with the
Americans with Disabilities Act (ADA). If
you need a reasonable accommodation
in accordance with the ADA, contact a
court clerk or an ADA contact person
listed at www.jud.ct.gov/ADA.
