Fill and Sign the Petition to Annul Record Jv New Hampshire Judicial Branch Form

NHJB-2317-DS (06/27/2013) Page 1 of 3 THE STATE OF NEW HAMPSHIRE JUDICIAL BRANCH htt p://www.courts.state.nh.us Court Name: Case Name: Case Number: (if known) Charge ID: PETITION TO ANNUL RECORD In accordance with RSA 651:5, the applicant requests that the Court annul the record of arrest and charge, and if applicable, conviction and sentence in the following matter: PLEASE COMPLETE A SEPARATE FORM FOR EACH OFFENSE APPLICANT’S INFORMATION Full Name : Date of Birth : Address : City/Town State Zip Code Telephone Number : E-mail Address : (optional) CHARGE INFORMATION For the charge that you are seeking to annul, list the RSA (statute) violated, name of crime/offense, date of offense, date of conviction or other disposit ion, date all terms and conditions of the sentence were completed, and disposition (sentence) imposed by the Court: RSA Violated Name of Crime/Offense Date of Offense Date of Conviction or Other Disposition Date Sentence Completed Description of Sentence or other Disposition: Case Name: Case Number: PETITION TO ANNUL RECORD NHJB-2317-DS (06/27/2013) Page 2 of 3 APPLICANT’S CERTIFICATION (Select checkbox that applies) The applicant was not convicted of the above crime/offense, and seeks only annulment of any record of arrest and/or charge. The applicant was convicted of the above crime/offense, and s eeks annulment of any record of arrest, the offense/charge, conv iction and sentence, and the applicant represents to the Court that: 1 All the terms and conditions of the sentence listed above have been completed, including the payment of any fine, restituti on or other cost, any probation per iod and any suspended sentence imposed by the Court. 2. The time requirements for an annulment under RSA 651:5, III have been met for the crime for which the applicant has been convicted. 3. Since completing the terms and conditions of the sentence imposed by the Court in these matters, the applicant has not thereafter been conv icted of any other crime, except a motor vehicle offense classified as a violation, other than dr iving while intoxicated under RSA 265-A:2, I, RSA 265:82 or RSA 265-82-a. 4.There are currently no char ges pending against the applicant in any other Court, except: 5. None of the charges sought to be annulled involve a violent crime, a crime of obstruction of justice, or an offense for which an ext ended term of imprisonment under RSA 651:6 was imposed. After considering the investigation report prepared by the Department of Corrections and any response filed by the Stat e, the Court may make a decision on y our Petition to Annul Record without a hearing. If you are requesting a hearing be fore a judge, please check the box. Date Applicant’s Signature Name of Counsel Counsel’s Signature Address State of , County of This instrument was acknowledged bef ore me on by My Commission Expires Affix Seal, if any Signature of Notarial Officer / Title Case Name: Case Number: PETITION TO ANNUL RECORD NHJB-2317-DS (06/27/2013) Page 3 of 3 FOR COURT USE ONLY: ON THE PETITION TO ANNUL RECORD OF ARREST OR CONVICTION AND SENTENCE The Court having found that notice of the forgoing petition was given in accordance with law, and having reviewed the investigative r eport of the Department of Corrections made in accordance with statute, finds that annulment of the applicant’s record will assist in the applicant’s rehabilitation and will be consistent with the public welf are and the requirements of law, IT IS THEREFORE ORDERED AND CERTIFIED: That the record of t he charge and disposition of dismissal, acquittal or nolle prosequi in the above referenced matter, together with any record of ar rest or charge therein is hereby annulled. The applicant has shown that issuance of this order is warranted under the statute. The clerk shall issue an appropria te Certificate of Annulment. That the record of convicti on and sentence in the above entitled case, together with any record of arrest or charge therein, is hereby annulled. The clerk shall is sue an appropriate Certificate of Annulment. The Court DENIES the applicant’s petition for the following reason(s): Date Signature of Judge Printed Name of Judge