REQUEST FOR ACCESS TO
PLAINTIFF CONFIDENTIAL INFORMATION
G.L. c. 209A, § 8 or G.L. c. 258E, § 10

DOCKET NO.

Massachusetts Trial Court

All requests for access to a Plaintiff’s confidential information must be submitted to the Clerk-Magistrate or Register on this form.  Requesters “shall present a valid
driver’s license or other suitable photographic verification of the person’s identity and signature and, as required by statute, set forth the reason(s) access to the
information is necessary in the performance of their duties.”    MASSACHUSETTS TRIAL COURT DIRECTIVE OF NOVEMBER 10, 2000.

REQUESTER’S NAME

PLAINTIFF’S NAME

CONFIDENTIAL INFORMATION TO WHICH ACCESS IS REQUESTED

BASIS FOR ACCESS

1. G Plaintiff or Plaintiff’s Attorney

2. G Authorized by Plaintiff to obtain such information

(Written authorization from Plaintiff must accompany request form unless requester is named in the Plaintiff Confidential Information form)

3. G Prosecutor

Name, address and telephone number of prosecuting agency:

4. G Law Enforcement Officer

Name, address and telephone number of law enforcement agency:

___________________________________________________________________________________________

_________________________________________________________________________________________________________________

5. G Victim-Witness Advocate (G.L. c. 258B, § 1)

Name, address and telephone number of prosecuting or other criminal justice agency: 

 ___________________________________________________________________________________________

6. G Sexual Assault Counselor (G.L. c. 233, § 20J)

Name, address and telephone number of sexual assault victims’ program: 

7. G Domestic Violence Counselor (G.L. c. 233, § 20K) (209A cases only)
Name, address and telephone number of domestic violence victims’ program: 

8. G Other, authorized by Court

(A copy of the Court’s order must accompany request form)

___________________________________________________________________________________________

___________________________________________________________________________________________

IF YOUR BASIS OF ACCESS IS (3) THROUGH (7) ABOVE, EXPLAIN HOW THE INFORMATION REQUESTED IS NECESSARY IN THE PERFORMANCE OF YOUR DUTIES
(G.L. c. 209A, § 8 or G.L. c. 258E, § 10 allow access only if necessary in the performance of your duties)

DATE

SIGNATURE OF PERSON REQUESTING ACCESS

TITLE

      x

 FA/HA-7 (5/10)