Fillable REQUEST TO SHIELD ADDRESS / TELEPHONE NUMBER / (Maryland Judiciary)

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REQUEST TO SHIELD ADDRESS / TELEPHONE NUMBER / (Maryland Judiciary)

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☐ CIRCUIT COURT ☐ DISTRICT COURT OF MARYLAND FOR
Date
Name
Month
Year
Date
Signature
ID Number
Located at Case No.
STATE OF MARYLAND or
vs.
REQUEST TO SHIELD ADDRESS / TELEPHONE NUMBER / E-MAIL ADDRESS
IN A CRIMINAL CASE RECORD
(Md. Rule 16-934(h))
I am the ☐ victim ☐ victim’s representative ☐ witness ☐ State’s Attorney in the case above.
☐ I am requesting the shielding of the:
☐ address ☐ telephone number ☐ e-mail address above
T
he reason this information should not be disclosed is:
I certify that I served a copy of this request upon the following party or parties by ☐ mailing first class mail,
postage prepaid, ☐ hand delivery, on to:
*You can redact or remove your address and/or telephone number on the copy served to the other party(ies).
ORDER / APPROVAL
ORDERED/APPROVAL, this day of , , by
that the above request to shield is: ☐ Granted ☐ Denied ☐ Shielding not required.
NOTICE: Remote access to the name, address, telephone number, date of birth, e-mail address and place of
employment of a victim or non-party witness is subject to blocking in accordance with Md. Rule 16-918.
If your request is denied, you have the right to file a Petition to Seal or Otherwise Limit Inspection of a
Case Record (form CC-DC-053).
CC-DC-052 (Rev. 07/2021)
City/County
Court Address
Victim/Victim’s representative/Witness (Please print.)
*Address
*City, State, Zip
Victim/Victim’s representative/Witness (Please print.)
*Address
*City, State, Zip
*Telephone Number
Name
Date
Signature of Party Serving/Attorney
Plaintiff/Complainant
Defendant/Respondent
Address
Address
City, State, Zip
City, State, Zip
*E-mail Address
RSHLR
Attorney Number
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REQUEST TO SHIELD ADDRESS TELEPHONE NUMBER (Maryland Judiciary)

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Completed 23 February 2022

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