Declaration For The Receipt Of Confidential Juvenile Information


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SUPERIOR COURT OF THE STATE OF CALIFORNIA, COUNTY OF NEVADA

DECLARATION FOR THE RECEIPT OF CONFIDENTIAL JUVENILE INFORMATION

I, __________________________________, request that information concerning a

traffic accident or

crime incident contained in

Nevada County Sheriff’s

Department Grass Valley Police Department Nevada County Police Department

California Department of Parks & Recreation Other _____________________

Case No. ___________________ be released to me. I acknowledge that the information

being released to me is CONFIDENTIAL, in that it contains information concerning one or

more juveniles.

I acknowledge that: (1) the information is being released to me pursuant to a Nevada County Juvenile Court Standing Order; and (2) my use of this information and the persons to whom I may disclose this information is restricted by that Order; and (3) that ANY VIOLATION OF AN ORDER OF A SUPERIOR COURT JUDGE, WHICH MAY SUBJECT ME TO PROSECUTION FOR CONTEMPT OF COURT under California Penal Code Section 166. Section IIIG of the Standing Order provides in pertinent part as follows:

“G. . . . The information is to be released only for purposes of assessing the person or entity in obtaining the reimbursement for injuries or damages caused by the conduct of the minor(s). The person to whom the information is released shall agree in writing that the person other than their attorney, insurance adjuster or other person legally representing the person’s or entity’s interest in recovering damages resulting from the incident. The person to whom the information is released shall also agree in writing that the information is released shall also agree in writing that the information will be used by them for no purpose other than as stated above . . .”

By my signature hereon, I acknowledge that I have read the above and understand its contents and agree not to make any use of disclosure of any of the information provided to me other than as allowed by the Juvenile Court as stated herein.

I declare under penalty of perjury that I, or a person or entity I am authorized to represent, was damaged by or a victim of the conduct of minor(s) who is the subject of the above listed law enforcement report. I (or the person or entity I represent) further declare that I have suffered injury or damages as a result of the conduct of said minor(s) and will use the information provided me only for the purpose of obtaining reimbursement for the injury or damage suffered by me.

Executed on ______________________________, at Nevada City, California.

______________________________ DECLARANT

________________________________________________________________________________________________________________________________________________

DECLARATION FOR THE RECEIPT OF CONFIDENTIAL JUVENILE INFORMATION

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LOCAL JV5 (Rev. 7/1/03) – OPTIONAL FORM

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Declaration For The Receipt Of Confidential Juvenile Information