Fill and Sign the Name and Address of Defendant Type or Print Form

I cert if y t hat an applicat ion under t he st at ut e ident if ied abov e and all af f idav it s required under t hat st at ut e hav e been f iled in t his case, t hat I hav e serv ed copies on t he dist rict at t orney , and t hat t he inf ormat ion set f ort h abov e is a complet e and accurat e st at ement of t he inf ormat ion on f ile in t he of f ice of t he Clerk of Superior Court . STATE V ERSUS STATE OF NORTH CAROLINA File No. (Ov er) Count y REQUEST AND REPORTS CONV ICTIONS/ EX PUNCTIONS DISM ISSALS AND DISCHARGE G. S. 1 5 A -1 4 5 , 1 5 A -1 4 6 , 9 0 -9 6 , 9 0 -1 1 3 . 1 4 Ex punct ion of records under: Dismissal of charges and discharge of def endant under: In The General Court Of J ust ice Dist rict Superior Court Div ision To The State Bureau Of Investigation, P. O. Box 2 9 5 0 0 , Raleigh, NC 2 7 6 2 6 : Please prepare, cert if y on t he rev erse side, and at t ach t o t his Request any Criminal Record Hist ory Inf ormat ion f or t he pet it ioner. Then f orw ard t his Request w it h Criminal Record Hist ory Inf ormat ion at t ached, conf ident ially t o: Records Of f icer, A dminist rat iv e Of f ice of t he Court s, Courier Box 5 6 -1 0 -5 0 , Raleigh, NC, OR if courier is not av ailable, mail t o P. O. Box 2 4 4 8 , Raleigh, NC 2 7 6 0 2 . To The Records Officer, Administrative Office of the Courts: Please complet e t he report on t he rev erse side and ret urn it , along w it h any Criminal Record Hist ory Inf ormat ion prev iously at t ached t o t his Request by t he SBI, t o t he Clerk of Superior Court , A t t n: Presiding J udge. REQUEST BY JUDGE Of f ense To Be Ex punged Or Dismissed Relief Request ed A nd St at ut e Under W hich A pplicat ion M ade (Check Only One) 1 5 A -1 4 6 9 0 -1 1 3 . 1 4 (d) 9 0 -9 6 (b) 9 0 -1 1 3 . 1 4 (e) 9 0 -9 6 (e 1 5 A -1 4 5 9 0 -1 1 3 . 1 4 (b) 9 0 -1 1 3 . 1 4 (a) 9 0 -9 6 (a) OFFENSE INFORM ATION Dat e Of f ense Commit t ed Dat e Of A rrest , Indict ment Or Serv ice Of Ot her Init iat ing Process Dat e Of Dismissal Or Finding Of Not Guilt y Dat e Of Guilt y Plea Or Dat e Found Guilt y Dat e Of Dismissal A nd Discharge Under G. S. 9 0 -9 6 (a) or G. S. 9 0 -1 1 3 . 1 4 (a) Dat e Of Conv ict ion DATE (Check A nd Giv e Dat e For A ll W hich A pply ) Name A nd A ddress Of Def endant ' s A t t orney OFFENSE INFORM ATION Def endant A t t orney Signat ure Signat ure Of Presiding J udge Dat e Name Of Presiding J udge (Ty pe Or Print ) Dat e 9 0 -9 6 (d) Name A nd A ddress Of Def endant (Ty pe Or Print ) A OC-CR-2 3 7 , Rev . 4 / 0 12 0 0 1 A dminist rat iv e Of f ice of t he Court s Social Securit y No. Sex Race G. S. No. Name A nd A ddress Of A rrest ing A gency DOB t here is a record under t he name of t he def endant ident if ied on t he rev erse side of t his f orm as f ollow s: t he Criminal Record Hist ory Inf ormat ion w hich is at t ached is a t rue and accurat e st at ement of all inf ormat ion cont ained in t he criminal records of t he St at e and Federal Bureaus of Inv est igat ion f or t he def endant ident if ied on t he rev erse side of t his f orm. A ssist ant CSC INSTRUCTIONS: 1 . 2 . 3 . 4 . 5 . 6 . 7 . 8 . 9 . To The Arresting Agency Identified On The Reverse And To The Records Officer, Administrative Office Of The Courts, Courier Box 5 6 -1 0 -5 0 , Raleigh, NC, OR if courier is not available, mail to P. O. Box 2 4 4 8 , Raleigh, NC 2 7 6 0 2 : CRIM INAL RECORD HISTORY INFORM ATION To Any Presiding Judge In The Above Named County And Court: (Conf ident ial) To Any Presiding Judge In The Above Named County And Court: (Conf ident ial) REPORT BY ADM INISTRATIV E OFFICE OF THE COURTS t here is no record under t he name of t he def endant of any ex punct ion or dismissal and discharge under any st at ut e of CERTIFICATION BY CLERK Signat ure Of Records Of f icer Signat ure Dat e Name (Ty pe Or Print ) Clerk Of Superior Court No order should be ent ered unt il t his f orm has been complet ed by t he def endant , a judge, S. B. I. and A OC and has been ref erenced t o t he Clerk as ex plained below . The def endant or at t orney should complet e all " Of f ense Inf ormat ion" on t he rev erse side of t his f orm f rom t he court f ile, sign t he cert if icat e, obt ain t he judge' s signat ure and send t o t he S. B. I. The S. B. I. shall t hen complet e CRHI and send t o t he A OC. The A OC shall complet e t he report and mail t o t he Clerk of Superior Court in t he count y w here t he ex punct ion is pending in an env eloped marked " A t t n: Presiding J udge-Conf ident ial-A OC-CR-2 3 7 Enclosed-File No. -Def endant ' s Name. " The Clerk places t he sealed env elope in t he f ile t o be opened by t he presiding judge w hen t he applicat ion is heard. It is t he responsibilit y of t he pet it ioner t o det ermine if t he A OC-CR-2 3 7 has been ret urned and t hen t o ask t he Clerk or D. A . t o schedule an applicat ion/ mot ion t o ex punge f or hearing. If order grant ing dismissal and discharge is ent ered, t he Clerk not if ies t he A OC. If Order of Ex punct ion is ent ered, t he Clerk makes t w o copies of t his f orm, complet es " Cert if icat ion By Clerk" on each copy , at t aches a copy of t he Order t o each copy , and sends one set of each t o arrest ing agency and t he A OC. The Clerk ret ains t he original t o be disposed of w it h t he papers in t his case. No ot her copy is made or kept . If applicat ion is denied, all copies of t he A OC-CR-2 3 7 and any accompany ing inf ormat ion f rom t he S. B. I. or A OC shall be dest roy ed, unless t he court orders ot herw ise. Upon t he complet ion of an applicat ion/ mot ion t o ex punge, or dismiss and discharge, w hich is a separat e document prepared by t he def endant or his at t orney , t he procedures f or t his f orm are as f ollow s: Signat ure Of S. B. I. Of f icial t here is no criminal record f or t he def endant ident if ied on t he rev erse side of t his f orm. Dat e Dat e A OC-CR-2 3 7 , Side Tw o, Rev . 4 / 0 1 2 0 0 1 A dminist rat iv e Of f ice of t he Court s I hav e conduct ed a search of t he criminal records of t he Nort h Carolina St at e Bureau of Inv est igat ion and t he Federal Bureau of Inv est igat ion, based on t he inf ormat ion prov ided by y ou, w hich has not been v erif ied by f ingerprint comparisons, and cert if y t hat I hav e searched t he conf ident ial f ile w hich cont ains t he names of all persons grant ed an ex punct ion or dismissal and discharge in Nort h Carolina and cert if y t hat I certify that this form and the attached Order are true and complete copies of the originals in this case and are being forw arded for compliance w ith any applicable provisions of the Order.