Fill and Sign the A Minor in the Juvenile Court of County Pennsylvania Form

In the Interest of: ___________________, a Minor IN THE JUVENILE COURT OF ______________ COUNTY, PENNSYL VANIA JUVENILE DIVISION DOCKET NO: _____________________ _ ORDER AND NOW, this ____ day of _______ ______, 20___, the Motion for Expungement is _________ ________________ ___________ . It is ORDERED that the record in this matter shall be expunged, and any fingerprints or photographs taken shall be destroyed. The Court specifically directs that the following items shall be expunge\ d: The Court specifically directs that the following items shall be destroy\ ed: The keeper of the juvenile records shall expunge the following items: The keeper of the juvenile records shall destroy the following items: Each agency, department, or office, upon request, shall notify the Court or its designee, in writing, of the action taken in response to the order to expunge or destroy. The school building principal or his or her designee is directed to destroy the information received from the court pursuant to Pa.R.J.C.P. 163. The information required under Rule Pa.R.J.C.P. 172 appears on the attached page(s) which is hereby incorporated into this ORDER by reference. BY THE COURT: Judge AOPC Rev. 7/1/2019 Page 1 of 2 In the Interest of: ___________________ , a Minor Expungement Order - Juvenile Docket No: _____________________ AOPC Rev. 7/1/2019 Page 2 of 2 1. Name of Juvenile: ___________________________________ _____ 2. Alias(es): __________________________________________ _____ 3. Date of Birth of Juvenile if known: __________ 4. The juvenile's case docket number, if any: ________________ _____ 5. The allegations or offenses to which the expungement order pertains: ________________________ ________ ______________________________________ ___________________________________ ________________________ ________ ______________________________________ ___________________________________ ________________________ ________ ______________________________________ ___________________________________ ________________________ ________ ______________________________________ ___________________________________ ________________________ ________ ______________________________________ ___________________________________ 6. The law enforcement agency that initiated the allegations: _________________________________________________________ 7. The reference number of the police report or written allegation to be expunged or destroyed , including the juvenile offense tracking number (JOTN) if available : _____________ 8. The date of arrest: ___________ 9. The reasons and statutory authority for expunging or destroying the documents, fingerprints, or photographs: 10. The agencies upon which certified copies of the court order shall be served: Statute Grade Description Disposition