ORDERED/APPROVAL, this day of , , by
that the above Request to Shield is: Granted Denied Shielding not required.
CIRCUIT COURT DISTRICT COURT OF MARYLAND FOR
Located at Case No.
Court Address
City/County
STATE OF MARYLAND or
vs.
Defendant /Respondent
REQUEST TO SHIELD MY ADDRESS / TELEPHONE NUMBER
IN A CRIMINAL CASE RECORD
(Md. Rule 16-912(g))
Victim/Victim's representative/Witness (Please print.)
Address
Telephone Number
CC-DC-052 (Restored and Revised 10/2017)
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 16-910.
If your request is denied, you have the right to file a motion (form CC-DC-053).
Signature
I.D. Number
Date
City, State, Zip
Victim/Victim's representative/Witness (Please print.)
Address
Telephone Number
City, State, Zip
Plaintiff/Complainant
I certify that I served a copy of this motion upon the following party or parties by mailing first class
mail, postage prepaid, hand delivery, on to:
Date
Name
Name
Address
Address
City, State, Zip
City, State, Zip
Date
Signature of Party Serving/Attorney/Attorney Code
ORDER / APPROVAL
Month
Year
I am the victim victim's representative witness in the case above.
I am requesting the shielding of the following information:
address
telephone number
The reason this information should not be disclosed is:
