REQUEST FOR SEX OFFENDER INFORMATION
FROM CITY/TOWN POLICE DEPARTMENTS

You may request 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 a one mile radius of a specific address; or whether any sex offenders live or work on a specific street.

If a sex offender is identified above, you will receive a report which indicates the name of the offender, the home address if it is within the one mile radius, the work address if within the one mile radius, the offense and dates for which the offender was convicted/adjudicated, the offender's age - sex - race - height - weight - eye and hair color, and a photograph if available.

All inquiries shall be recorded and kept confidential; provided that the records may be disseminated to assist any criminal prosecution.
 

NAME OF REQUESTOR _______________________________________

ADDRESS __________________________________________________

TOWN ______________________________ STATE ______ ZIP _______

PHONE ___________________

DATE OF BIRTH  _____________  DATE OF REQUEST _____________

REASON FOR INQUIRY:

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I SWEAR, UNDER THE PAINS AND PENALTIES OF PERJURY, THAT I AM THE ABOVE-NAMED PERSON, HAVE ATTAINED THE AGE OF 18 YEARS AND 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 EIGHTEEN (18) OR ANOTHER PERSON FOR WHOM I HAVE RESPONSIBILITY, CARE OR CUSTODY.  I FURTHER UNDERSTAND THAT INFORMATION CONTAINED IN THE SEX OFFENDER REPORT SHALL NOT BE USED TO COMMIT ANY CRIMES AGAINST ANY SEX OFFENDER OR TO ENGAGE IN ILLEGAL DISCRIMINATION OR HARASSMENT OF AN OFFENDER.  ANY PERSON WHO USES INFORMATION DISCLOSED PURSUANT TO THIS ACT TO COMMIT A CRIME SHALL BE PUNISHED BY NOT MORE THAN TWO AND ONE HALF YEARS (2.5) IN A HOUSE OF CORRECTION OR BY A FINE OF NOT MORE THAN ONE THOUSAND DOLLARS ($1,000) OR BY BOTH SUCH FINE AND IMPRISONMENT PURSUANT TO MASSACHUSETTS GENERAL LAWS, CHAPTER 6, SECITON 178J.  IN ADDITION, ANY PERSON WHO USES INFORMATION DISCLOSED PURSUANT TO THIS ACT 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 (6) PURSUANT TO MASSACHUSETTS GENRERAL LAWS, CHAPTER 275, SECTION 4.

DATE __________  Signature ____________________________________
If you are inquiring whether an individual is a sex offender, please complete the following section:
SUBJECT'S NAME ____________________________________________

PERSONAL IDENTIFYING CHARACTERISTICS:
   SEX ______    RACE ______    HGT ______    WGT ______
   EYE COLOR ______    HAIR COLOR ________

If you are inquiring whether and sex offenders live or work on a specific street, please complete the following section:
STREET ______________________________________________
CITY _________________________

If you are inquiring whether any sex offenders live or work within a one mile radius of a specific address, please complete the following section:

ADDRESSES:

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