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COMMONWEALTH OF MASSACHUSETTS

SEX OFFENDER REGISTRY BOARD

REQUEST FOR SEX OFFENDER REGISTRY INFORMATION

All requests for sex offender information must be made on this form and mailed to the Sex Offender Registry Board, P.O.

Box 4547, Salem, MA 01970, along with a self-addressed stamped envelope. The Board will provide a report that includes

the following information: whether the person identified is a sex offender with an obligation to register, the offense(s) for

which the offender was convicted or adjudicated, and the date(s) of the conviction(s) or adjudication(s). Please be advised

that the law only permits the public to receive information on sex offenders required to register and finally classified by the

Board as a level 2 (moderate risk) or level 3 (high risk) offender. Therefore, information is not available to the public if the

identified individual is a level 1 (low risk) offender or if he/she has not yet been finally classified by the Board.

All requests shall be recorded and kept confidential, except to assist or defend in a criminal prosecution.

Requestor’s name: _____________________________________

Date of birth: ________________________

Address: _____________________________________________

Telephone number: ___________________

_____________________________________________

I swear under the pains and penalties of perjury that I am the above-named person, at least 18 years of age, and I am

requesting information for my own protection, the protection of a child under 18 years of age, or for the protection of another

person for whom I have responsibility, care or custody.

Requestor’s signature: __________________________________

Date: ____________________________

I hereby request that the following information be used to determine whether the identified individual is a sex offender

required to register in Massachusetts.

Subject’s name: _______________________________________________

Date of birth or approximate age: ________________________________

Address: ____________________________________________________________________________________________

Personal identifying characteristics:

Sex: ______

Race: ______

Height: ______

Weight: ______

Eye Color: ______

Hair Color: ______

Other information (e.g. license plate number, parents’ names, etc.): _________________________________________

____________________________________________________________________________________________________

**********WARNING**********

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 (6) MONTHS ( M.G.L. C. 275, § 4).

Request For Sex Offender Registry Information Form - Sex Offender Registry Board Commonwealth Of Massachusetts