1. The undersigned is a victim of a sex offense as defined under the N.D. Cent. Code Chapter 12.1-20 or, in the case of a minor, the parent or legal guardian of the minor identified below, who is a victim of a sex offense as defined under said statutes.

2. Pursuant to N.D. Cent. Code § 23-07.7-01, the undersigned hereby requests the appropriate prosecuting attorney to petition the Court for an order that the defendant or alleged juvenile offender charged with perpetrating the sex offense against me or the minor identified below, be required to undergo testing to determine whether the defendant or alleged juvenile offender has any sexually transmitted disease, including a test for infection with the human immunodeficiency virus or any other identified positive agent of acquired immunodeficiency syndrome.

3. [T]he undersigned further requests that this document be filed with the court and that the prosecutor requests that the file be sealed so as to prevent public disclosure of this and other related documents.