NDLSHC Page 1 of 3 Affidavit Prohibit Pub Access/Rev Jan 2020

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STATE OF NORTH DAKOTA IN DISTRICT COURT

COUNTY OF _________________________ ____________________ JUDICIAL DISTRICT

THE STATE OF NORTH DAKOTA ) PLAINTIFF, ) Criminal Case No. _____________________ ) vs. ) ) AFFIDAVIT IN SUPPORT OF MOTION TO ____________________________ ) PROHIBIT PUBLIC ACCESS DEFENDANT. )

I, ___________________________________________________________________, the

undersigned, state as follows:

1. I am the defendant in the above-captioned criminal case(s).

2. I was charged on ______________________________________________________ with

______________________________________________________________________________

_____________________________________________________________________________.

3. On _______________________________________________________, the charge(s)

against me was/were dismissed / I was acquitted of the charge(s).

4. In the above-captioned criminal case(s), the reason for dismissal of charge(s) /

acquittal was ________________________________________________________________

______________________________________________________________________________

_____________________________________________________________________________.

5. Because the records have remained available for public access, I have sustained or am

likely to sustain the following harms: _______________________________________________

______________________________________________________________________________

______________________________________________________________________________

NDLSHC Page 2 of 3 Affidavit Prohibit Pub Access/Rev Jan 2020

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Additional sheets are attached as Exhibit B.

NDLSHC Page 3 of 3 Affidavit Prohibit Pub Access/Rev Jan 2020

6. I declare, under penalty of perjury under the law of North Dakota, that everything I

stated in this Affidavit is true and correct.

STATE OF ) ) COUNTY OF _________________________ ) ss. ) COUNTRY OF _________________________ ) Signed on this _____ day of ___________________________, 20______.

________________________________________________ Defendant Signature

Printed Name

Address

City, State, Zip Code

Telephone Number