Juvenile Record Affidavit Form

JUVENILE RECORD AFFIDAVIT FORM

This Juvenile Record Affidavit (this Affidavit) is executed on Date: by Affiant Name: , whose current address is , and whose date of birth is . The receiving party for this Affidavit is Agency or Recipient Name: with address .

RECITALS

WHEREAS, Affiant was the subject of one or more juvenile court matters and seeks to provide an accurate sworn statement regarding the existence, disposition, sealing or expungement of those juvenile records; and

WHEREAS, the Receiving Agency requires a sworn affidavit that identifies each juvenile matter to the best of Affiant's knowledge, specifying court, case number, adjudication or diversion, disposition, and the current sealing or expungement status; and

WHEREAS, Affiant understands and acknowledges that any material misstatement in this Affidavit may subject Affiant to penalties for perjury and other civil or criminal liabilities under applicable law.

NOW, THEREFORE, in consideration of the foregoing and the covenants contained herein, Affiant hereby declares and affirms under oath as follows:

1. DECLARATION OF IDENTITY

1.1 Affiant declares that Affiant's full legal name at birth, if different, and current legal name are as follows: Name at Birth: ; Current Legal Name: .

1.2 Affiant may provide the last four digits of Social Security Number for identification: . Providing the Social Security information is voluntary and will be used only for verification.

2. STATEMENT OF JUVENILE MATTERS

Affiant lists known juvenile matters below. For each matter, provide the juvenile court name, case number, approximate date of adjudication or diversion, disposition, and whether the record has been sealed or expunged. If more space is required, attach additional sworn pages and mark them as attachments to this Affidavit.

Sealing/Expungement Status: Sealed Expunged If sealed/expunged, date:

Sealing/Expungement Status: Sealed Expunged If sealed/expunged, date:

3. AUTHORIZATION, RELEASE, AND USE

3.1 Affiant authorizes the Receiving Agency and its agents to verify the information provided in this Affidavit, to request certified court dispositions from juvenile court clerks, and to rely upon the representations made herein for purposes permitted by law. Affiant expressly releases juvenile courts, law enforcement agencies, and the Receiving Agency from liability for disclosure made in good faith and in accordance with applicable statutes.

3.2 Affiant understands that this Affidavit is provided for the limited purpose identified herein and does not itself effect sealing or expungement; any legal relief regarding sealing or expungement must be obtained through court process as provided by law.

4. CERTIFICATION AND PENALTY FOR FALSE STATEMENTS

4.1 Affiant certifies under penalty of perjury under the laws of the governing jurisdiction that the statements contained in this Affidavit are true and correct to the best of Affiant's knowledge, information and belief. Affiant acknowledges that knowingly making a false statement in this sworn instrument may subject Affiant to criminal prosecution, civil penalties, or denial of benefits.

5. NOTICES

Any notice required or permitted under this Affidavit shall be sent to the addresses listed above. Notices sent by mail are effective upon deposit with the United States Postal Service; notices delivered by hand are effective upon receipt.

6. MISCELLANEOUS

Governing Law: This Affidavit shall be governed by and construed in accordance with the laws of the state in which the Receiving Agency is located, without regard to conflict of law principles.

Entire Agreement: This Affidavit constitutes the entire sworn statement between the parties on the subject matter herein and supersedes all prior written or oral statements and agreements solely to the extent they relate to the sworn matters described herein.

Severability: If any provision of this Affidavit is held invalid or unenforceable, the remainder of this Affidavit shall remain in full force and effect and such provision shall be reformed only to the extent necessary to make it enforceable.

Amendments; Waiver: No amendment, modification or waiver of any provision of this Affidavit shall be effective unless in a writing signed by Affiant and an authorized representative of the Receiving Agency. No waiver shall be implied from conduct or failure to enforce rights.

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