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The Commonwealth of Massachusetts Executive Office of Public Safety Sex Offender Registry Board Post Office Box 4547 Salem, MA 01970-4547 (978) 740-6400 Fax: (978) 740-6464 Deval L. Pat rick Governor Timothy P. Murray Lieutenant Govenor Kevin M. Burke Secretary Saundra Edwa ds r Chairperson REQUEST FOR SEX OFFENDER INFORMATION FROM CITY/TOWN POLICE DEPARTMENTS (M.G.L. c. 6, § 178J) You may request from your city/town police department whether: a specific individual identified by name, date of birth or sufficient personal identifying characteristics is a sex offender; or whether any sex offenders live or work within the same city or town of a specific address. You may specify the address of a home, school, daycare facility, playground, etc.; or whether any sex offenders live or work on a specific street. In response to your request, you will receive a report which indicates the name of the offender, the home address, the work address, the offense(s) and date(s) for which the offender was convicted/adjudicated, the offender's age-sex-race-height-weight-eye and hair color, and a photograph if available. Please be advised that the law only permits the public to receive information on sex offenders required to register and finally classified by the Sex Offender Registry Board as a level 2 (moderate risk) or level 3 (high risk) offender. Therefore, information is not available to the public if the sex offender is a level 1 (low risk) offender or if he/she has not yet been finally classified by the Board. All inquiries shall be recorded and kept confidential; provided that the records may be disseminated to assist or defend any criminal prosecution. NAME OF REQUESTOR: ADDRESS: CITY/TOWN,STATE,ZIP: DATE OF BIRTH: DATE/TIME OF IDENTIFICATION SOR Form 5 (01/01) ---PAGE BREAK--- SOR Form 5 (01/01) If you are inquiring whether an individual is a sex offender, please complete the following section: SUBJECT'S NAME: PERSONAL IDENTIFYING SEX: RACE: D.O.B./APPROXIMATE AGE: ADDRESS: HGT: WGT: EYE COLOR: HAIR COLOR: OTHER PERTINENT INFORMATION (i.e. vehicle license plate number, parent information): * If you are inquiring whether any sex offenders live or work on a specific street, please complete the following section: STREET: * If you are inquiring whether any sex offenders live or work within the same city or town of a specific address, please complete the following section: ADDRESSES: “ I understand that the sex offender registry information disclosed to me is intended for my own protection or for the protection of a child under the age of 18 or another person for whom I have responsibility, care or custody.” M.G.L. c. 6, § 178J(a)(4) SIGNATURE OF REQUESTOR: SEX OFFENDER REGISTRY INFORMATION SHALL NOT BE USED TO COMMIT A CRIME OR TO ENGAGE IN ILLEGAL DISCRIMINATION OR HARASSMENT OF AN OFFENDER. ANY PERSON WHO USES INFORMATION DISCLOSED PURSUANT TO M.G.L. C. 6, 178C – 178P FOR SUCH PURPOSES SHALL BE PUNISHED BY NOT MORE THAN TWO AND ONE HALF (2 ½) YEARS IN A HOUSE OF CORRECTION OR BY A FINE OF NOT MORE THAN ONE THOUSAND DOLLARS ($1000.00) OR BOTH (M.G.L. C. 6, § 178N). IN ADDITION, ANY PERSON WHO USES REGISTRY INFORMATION TO THREATEN TO COMMIT A CRIME MAY BE PUNISHED BY A FINE OF NOT MORE THAN ONE HUNDRED DOLLARS ($100.00) OR BY IMPRISONMENT FOR NOT MORE THAN SIX MONTHS ( M.G.L. C. 275, §