Expungement Petition Form

EXPUNGEMENT PETITION FORM

Petitioner Name:   Date of Birth:   Address:

Respondent / Prosecuting Authority:   Case Number:   Court:

RECITALS

WHEREAS, Petitioner asserts that he or she is the person named above and was charged, arrested, or convicted as set forth in this petition and that relief by expungement is contemplated by applicable statute or court rule; and

WHEREAS, the conviction(s) and/or arrest(s) listed herein have resulted in collateral consequences to Petitioner and Petitioner seeks expungement of such records to restore rights and mitigate such consequences; and

WHEREAS, Petitioner certifies under penalty of perjury that the statements and facts set forth in this petition are true and that Petitioner is eligible under the law for the relief requested.

NOW THEREFORE, Petitioner petitions the court for an order expunging or sealing the records identified below and states as follows.

1. JURISDICTION

This Court has jurisdiction over this petition pursuant to the laws and rules governing expungement in the state in which the conviction was entered. Petitioner submits that venue is proper in .

2. PETITION FOR RELIEF

Petitioner requests an order expunging, sealing, or otherwise setting aside the arrest, charge, conviction, and disposition records described below so that such records are not publicly accessible and may be treated as vacated for purposes of employment, licensing, and civil rights restoration to the extent permitted by law.

3. CONVICTION(S) / ARREST(S) TO BE EXPUNGED

Offense 1

Charge/Offense:   Statute/Code:

Docket / Case No.:   Date of Arrest:   Date of Conviction/Disposition:

Disposition (plea, verdict, dismissal):

Sentence / Penalty Imposed:

Additional convictions or arrests are described in attached Exhibit A: Yes

4. GROUNDS FOR EXPUNGEMENT

Petitioner asserts eligibility for expungement based on the following grounds (check all that apply) and submits supporting factual statements below:

Completion of sentence, probation, parole, and satisfaction of all fines and restitution

Pardon or executive clemency

Juvenile adjudication or youth offender statute qualifying under law

Actual innocence or factual innocence supported by newly discovered evidence

5. SERVICE AND NOTICE

Petitioner will provide notice of this petition to the prosecuting authority and any law enforcement agency with custody of records in accordance with applicable law. Service was accomplished as follows:

Name and Title of Person Served:

Agency Served:   Date of Service:

6. SUPPORTING DOCUMENTS

Petitioner attaches the following documents to support this petition and incorporates them by reference as if fully set forth herein:

7. DECLARATION, CERTIFICATION AND OATH

Petitioner declares under penalty of perjury under the laws of the state that the foregoing is true and correct. Petitioner understands that an intentionally false statement may subject Petitioner to penalties for perjury and may be grounds for denial of relief.

8. RELIEF REQUESTED

WHEREFORE, Petitioner respectfully requests that the Court:

1. Enter an order expunging or sealing the records identified above; and

2. Direct law enforcement agencies, courts, and state repositories to update or remove references to the arrest, charge, conviction, and disposition to the extent required by law; and

3. Grant such further relief as the Court deems just and proper.

GOVERNING LAW; MISCELLANEOUS

Governing Law: This petition and any order entered hereon shall be governed by and construed in accordance with the laws of the state in which the underlying conviction or arrest occurred.

Entire Agreement: This petition constitutes the entire statement of the Petitioner on the matters herein and supersedes any prior oral or written representations with respect to the relief requested.

Severability: If any provision of this petition is held invalid, illegal, or unenforceable, the remaining provisions shall remain in full force and effect.

Amendments and Waiver: No waiver or amendment of any provision of this petition shall be effective unless in writing and signed by the party granting the waiver. Failure to assert any right shall not constitute a waiver.

Counterparts: This petition may be executed in counterparts, each of which shall be deemed an original, and all of which together shall constitute one instrument.

NOTICES

Notices required by this petition shall be sent to Petitioner at the address set forth above or to counsel of record at the contact information provided below.

VERIFICATION

I, the undersigned Petitioner, verify under penalty of perjury under the laws of this state that the matters set forth in this petition are true and correct to the best of my knowledge and belief.

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