Fill and Sign the New York Sealing Records Form

New York State Division of Criminal Justice Services Record Review Unit 4 Tower Place Albany, NY 12203-3764 Re: Name: ___________________ NYSID # ___________________ Address: ___________________ Soc. Sec. # ___________________ ___________________ Dear Sir/Madam, A review of the above-named individual’s DCJS rap sheet revealed cases that should have been sealed. I am writing to request that the following cases decided after 11/1/91 be sealed: as a conviction for a violation pursuant to CPL § 160.55, or for a violation of PL § 221.05 pursuant to CPL § 160.50. Enclosed please find the Certificate of Disposition. Docket Number Disposition Date of Conviction ___________________ ____________________________ ___________________ ___________________ ____________________________ ___________________ ___________________ ____________________________ ___________________ as an arrest that was terminated in the defendant’s favor under CPL §160.50. Enclosed please find the Certificate of Disposition. Docket Number Disposition Date of Arrest ___________________ ____________________________ ___________________ ___________________ ____________________________ ___________________ ___________________ ____________________________ ___________________ as an arrest that was terminated in a decline prosecution under CPL §160.50. Enclosed please find the 343-Dismissal form from the District Attorney. Arrest Number Date of Arrest ___________________ ___________________ Please notify me of the outcome of this request. Thank you for your time and attention. Sincerely,