Fillable Vnr Paper Application Form 0 (Commonwealth of Massachusetts)

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Vnr Paper Application Form 0 (Commonwealth of Massachusetts)

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U.S.A. forms for Commonwealth of Massachusetts

BROWSE COMMONWEALTH OF MASSACHUSETTS (MA) FORMS

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Massachusetts Department of Criminal Justice Information Services
Victim Services Unit
200 Arlington Street, Suite 2200, Chelsea, MA 02150
Phone Number 617.660.4690 Fax Number 617.660.5973
mass.gov/cjis/vsu
*Check one:
Request for Notice of Offender Release
Request for Access to CORI (Criminal Offender Record Information)
Change of address only (complete section F)
Section A: APPLICANT INFORMATION
*Applicant
Type:
Victim
Witness
Family Member
Concerned Citizen (Citizen Initiated Petition)
*If you are a Parent/Guardian of a minor witness please provide Minor Witness Information below:
*Print Minor
Witness Name:
(Last) (First) (Middle)
(Check One)
Section B: VICTIM INFORMATION
(*Mandatory when Applicant Type is Family Member )
Asian
Race:
Gender:
Female
Male
Ethnicity:
(Check One)
UnknownNon Hispanic
HispanicAsian
(Check One)
Black Unknown
Special Accommodations Required:
American Indian White
(Check One)
Last four digits of Social
Security Number:
*Applicant Date of Birth:
(MM/DD/YYYY)
*Print Applicant Name:
(Last) (First) (Middle)
*Mailing Address 1:
(Street No. and Name or PO Box Number) (Zip Code)
Mailing Address 2:
(Apt., Building or Box No.)
(State)(City)
Residential Address:
(If Different)
(Street No., Street Name, Apt., or Building) (City) (State) (Zip Code)
(In Care of Name)
(Country)
(Country)
Home Phone Number: Work Phone Number:
Alternate Phone Number:Cell Phone Number:
Formerly Known As/Other Names:
(Maiden Name, Also Known As)
(Last) (First)
(Middle) (Suffix)
Applicant E-mail Address:
(Suffix)
Applicant agrees to receive communications
by e-mail.
(Last)
(First) (Middle)
(Suffix)
*Telephone:
(One No. Mandatory)
*Denotes Required Field
DCJIS VSU FORM 0001
*Applicant Relationship
to Victim:
(Check one if Applicant Type is
Family Member or Concerned Citizen)
Parent/Guardian of the minor victim+
Parent/Guardian of deceased victim+
Parent/Guardian of incompetent victim+
Parent/Guardian of deceased victim's minor child+
Parent/Guardian of adult victim (Minor at time of crime)
No Relation
Offender's relative
Offender's ex-spouse
Parent/Guardian of incompetent victim's minor child+
Family member of adult victim
Cousin of deceased victim
Dependent person of deceased victim+
Dependent person of incompetent victim+
Niece/Nephew of deceased victim
Aunt/Uncle of deceased victim
Stepparent of minor victim+
Stepparent of deceased victim+
Sibling of minor victim+
Sibling of deceased victim+
Partner of deceased victim
Sibling of incompetent victim+
Grandchild of deceased victim
Stepchild of deceased victim+
Child of deceased victim+
Person with whom the deceased victim lived in a relationship similar to marriage
Stepchild of incompetent victim+
Grandparent of deceased victim
Child of incompetent victim+
Stepparent of incompetent victim+
Spouse of incompetent victim+
Spouse of deceased victim+
*Print Victim Name:
(Last)
(First) (Middle)
*Victim Date of Birth:
(MM/DD/YYYY)
+ denotes Applicant Relationship
types eligible for access to CORI
documents
Section D: CASE INFORMATION
Section E: ADVOCATE INFORMATION
Print Advocate Name:
(Last) (First) (Middle)
Mailing Address:
(Street No. and Name or PO Box Number) (Zip Code)(State)(City)
Advocate County:
Phone Number:
Fax Number: E-mail Address:
*Signature of Applicant:
Section H: APPLICANT SIGNATURE
*Date:
Section G: TERMS AND CONDITIONS
Concerned Citizen Condition: By selecting Applicant Type Concerned Citizen (Citizen Initiated Petition), I attest, under penalty
of perjury, that my safety is in jeopardy. Submitting this application with my signature is evidence of my testament.
Providing Information: The information requested is necessary to process your request for victim services and is voluntary.
Failure to provide any of the information requested may prevent the DCJIS Victim Services Unit from processing your
application. All information will remain confidential.
*New Mailing Address 1:
(Street No. and Name or PO Box Number) (Zip Code)
New Mailing Address 2:
(Apt., Building or Box No.)
(State)(City)
New Residential Address:
(If Different)
(Street No., Street Name and Apt., or Building) (City) (State) (Zip Code)
(In Care of Name)
(Country)
(Country)
*Print Applicant Name:
(Last) (First) (Middle)
(Suffix)
MAIL OR E-MAIL COMPLETED FORM TO:
Massachusetts Department of Criminal Justice Information Services
Victim Services Unit
200 Arlington Street, Suite 2200, Chelsea, MA 02150
VNR.info@state.ma.us
(*See documentation requirements on Page 3)
*Massachusetts Probation Central File (PCF) Number:
Race:
American Indian
Asian
Black
White
Unknown
Ethnicity:
Asian
Hispanic Non Hispanic Unknown
*Offender Date of Birth:
(MM/DD/YYYY)
Alias Names:
(Last)
(First)
(Suffix)(Middle)
*Offender Gender:
Female Male
(Check One)
(Last)
(First)
(Suffix)(Middle)
*Print Offender Name:
(Last) (First) (Middle)
(Suffix)
Section C: OFFENDER INFORMATION
DCJIS VSU FORM 0001
(Check One)
(Check One)
Commitment Number:
*Docket Number:
Housing Facility/
Supervising Agency:
*Custodial Agency:
Section F: CHANGE OF ADDRESS
*Telephone :
(Please supply a contact number for questions)
*Approved File/Certification#:
(*Advocate may sign/submit on behalf of applicant)
*Offender Social Security Number:
Submit by E-mail
INSTRUCTIONS
Massachusetts Department of Criminal Justice Information Services
Victim Services Unit
200 Arlington Street, Suite 2200, Chelsea, MA 02150
Phone Number 617.660.4690 Fax Number 617.660.5973
mass.gov/cjis/vsu
Questions? Call the DCJIS VSU at (617) 660-4690 for assistance!
Read the following instructions carefully before filling out the application form so that it can be processed correctly.
Check one of the three boxes at the top of the application form to indicate if this is a Request for Notice of Offender
Release, Request for Access to CORI (Criminal Offender Record Information), or Change of address only. If you
check the "Change of address only" box, complete section F only.
Section A: APPLICANT INFORMATION
Clearly print your name, formerly known as/other names (if
you have any), mailing address, residential address (if
different), telephone number where you can be reached, and
e-mail address (if you prefer to be contacted by e-mail in lieu
of standard mail).
Enter your date of birth.
Applicant Type: Check the box that most accurately describes
your relationship to the offender: Victim, Witness, Concerned
Citizen (Citizen Initiated Petition), or Family Member. *If you
are a Parent/Guardian of a minor witness, please provide the
minor witness name.
Applicant Relationship to Victim: If your Applicant Type is not
Victim or Witness, check the box that most accurately
describes your relationship to the victim.
Provide as much additional information as you have (e.g. last
four digits of social security number, gender, ethnicity, race,
and special accommodations). Please note that providing this
information is optional.
Note: It is your responsibility to keep the DCJIS VSU informed
of changes to your personal information.
Section D: CASE INFORMATION
Section B: VICTIM INFORMATION
(Complete Section B only when Applicant Type is Family
Member)
Clearly print the victim name.
Enter victim date of birth.
Check the box that most accurately describes your
relationship to the victim.
Section C: OFFENDER INFORMATION
Clearly print offender name and offender alias names (if any).
Enter offender date of birth and social security number. Check
the box that most accurately describes the offender's gender.
Enter the offender's Massachusetts Probation Central File
(PCF) Number.
Provide offender ethnicity and race (if available).
Note: Provide as much information as you can in this section so we
can be sure that we have the correct offender involved in your case.
Clearly print the docket number. *Docket number and
*Custodial Agency are required to fully process your
application for Notice of Offender Release. Custodial Agency
is not required for Access to CORI applications.
If you do not have a docket number, you must provide
related case information. Any one (1) of the following items
qualifies as related case documentation: Police Report;
District Attorney Summons; or Letter from a Prosecutor
Victim Witness Advocate. If you do not have a Docket
Number, attach your related case documentation to your
completed application and mail it to the DCJIS Victim
Services Unit at the address above.
Provide any optional information you have for housing
facility/supervising agency, custodial agency, and
commitment number.
Section E: ADVOCATE INFORMATION
Section G: TERMS AND CONDITIONS
Section H: APPLICANT SIGNATURE
Clearly print your advocate's name (if you have one),
mailing address, county, telephone number, fax number,
and e-mail address (if available).
The Victim Rights Law (M.G.L. c. 258B) allows victims,
witnesses, and family members of minor, deceased, or
incompetent victims to be notified by the appropriate
custodial authority whenever the offender is transferred to a
less secure facility, escapes from custody, or receives a
temporary, provisional, or final release. In addition, any
person who reasonably believes that his/her safety is at risk
from an offender may apply for notification. The Criminal
Offender Record Information (CORI) Law (M.G.L. c.6,
s.178A) mandates that victims, witnesses, family members
of deceased, incompetent, or minor aged victims, and
parent/guardians of minor witnesses shall, upon request, be
certified to receive CORI from criminal justice agencies. The
CORI Law also mandates that any person who reasonably
believes that his/her physical safety is at risk by an inmate
shall, upon request, be notified, in advance, of an
offender's release under a Citizen's Initiated Petition
(Concerned Citizen).
You must sign and date the form for DCJIS VSU to process.
Forms without a signature will be returned.
DCJIS VSU FORM 0001
Clearly print your approved file/certification #, name, new
mailing address, new residential address (if different), and
telephone number where you can be reached if necessary.
Section F: CHANGE OF ADDRESS
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Vnr Paper Application Form 0 (Commonwealth of Massachusetts)

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Completed 27 July 2020

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