Fill and Sign the Petition for Expungement Pursuant to Parcrimp 9122b Form

CRIMINAL ) COMMONWEALTH OF PENNSYLVANIA ) ) ) Defendant ) Motion to Expunge Defendant, , hereby moves the (Name of Defendant) Court for an Order of Expungement, and in support thereof, represents as follows: 1. The Defendant’s date of birth is 2. The Defendant’s Social Security Number is 3. On , the Defendant was charged with (date of arrest) (list all charges) 4. At the time of the arrest, the Defendant was photographed, fingerprinted, and a record of the arrest was made by the Police Department. 5. The Offense Tracking Number (OTN) is I IN THE COURT OF COMMON PLEAS OF _______________ COUNTY, PENNSYLVANIA vs. ) Docket Number 6. The Magisterial District Court Number for this case is 7. The Magisterial District docket number is 9. The charge(s) was disposed by a: 10. The charge(s) was disposed by the Court in the following manner (please check the appropriate box): Defendant was placed on the ARD Program, and he/she successfully completed the prescribed program and complied with its conditions (Certification attached). Charge(s) was withdrawn or dismissed Defendant was found not guilty of the charge(s). Governor’s Pardon (Copy Attached) Petitioner has reached 70 years of age and has been free of arrest or prosecution for ten years following final release from confinement or supervision. Defendant was convicted of a Summary Offe nse and he/she has been free of arrest or prosecution for five years following the conviction of that offense. 8. The Common Pleas docket number is Magisterial District Judge of _________ County Judge of the ___________ County Court of Com mon Pleas 11. There exists no compelling interest or overriding societal interest in retaining and maintaining the aforementioned records, reports, and fingerprints. 12. The presence of these records will be harmful to the Defendant’s reputation, and is likely to prejudice his/her employment and education. WHEREFORE, the Defendant respectfully requests this Honorable Court to order the expungement of all records pertaining to the aforementioned charge(s) under 18 Pa.C.S.A. §9122. RESPECTFULLY SUBMITTED: ______________________________ Defendant’s Signature VERIFICATION The undersigned Defendant avers that the statements of fact combined in this Motion for Expungement are true and co rrect to the best of the Defendant’s knowledge, information, and belief, and are made subject to the penalties of 18 PaC.S.A. §4904 relating to unsworn falsification to authorities. _____________________________________ __________________ Defendant’s Signature Date