200-00631 – Request for Sealing Order in Special Index (09/2019) Page 1 of 1
STATE OF VERMONT
SUPERIOR COURT CRIMINAL DIVISION
REQUEST FOR SEALING ORDER IN SPECIAL INDEX
Pursuant to 13 V.S.A. § 7607(e)
Requestor Information
Name of Person Requesting Sealing Order ______________________________________________
Name of Requestor’s Criminal Justice Agency ______________________________________________
Phone Number ______________________________________________
Email Address ______________________________________________
Mailing Address ______________________________________________
Information Regarding Sealing Order Requested
Defendant’s name (required) ______________________________________________
Defendant’s date of birth (required) ______________________________________________
County of venue (required) ______________________________________________
Docket number ______________________________________________
Charge ______________________________________________
By signing below, I swear that I am requesting this Sealing Order in accordance with my employment with
a criminal justice agency as defined in 20 V.S.A. § 2056a for criminal justice purposes as defined in
20 V.S.A. § 2056a. I declare that the above statement is true and accurate to the best of my knowledge and
belief. I understand that if the above statement is false, I will be subject to the penalty of perjury.
Date
_____________________________ _________________________________________
Signature of Requestor
