SORI FORM

Requestor’s name:

First Name Last Name
Date

Month Day Year
Date
Organization name: (if any)
Address:
Phone Number

Area Code Phone 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: *

Clear
Date

Month Day Year
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 Full Name *

First Name Middle Name Last Name
Date of birth or approximate age:

Month Day Year
Date
AGE
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
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 – 178Q 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).
Should be Empty: