Fill and Sign the Petition to Expunge for Nh Circuit Court Fill Online Form

NHJB-2135-DF (01/01/2011) Page 1 of 2 THE STATE OF NEW HAMPSHIRE JUDICIAL BRANCH htt p://www.courts.state.nh.us Court Name: Case Name: Case Number: (if applicable) PETITION TO EXPUNGE (REMOVE) Pursuant to RSA 169-C:35 1. Petitioner Name Date of Birth Social Security Number Residence Address Mailing Address (if different) Telephone Number (Home) (Work) 2. Child’s Name Date of Birth 3. Date of Court Finding (if applicable) 4. The petitioner stat es as follows: a. Pursuant to RSA 169-C:35, my name was listed as reported by the New Hampshire Department of Health and Human Services, Divis ion for Children, Youth and Families (“the Department”) as of (date) on the State’s Central Registry of founded reports of abuse and neglect. It has been: More than one (1) year since the date my name was entered on the State’s Central Registry; OR Three (3) or more years since the denial of my last Petition to have my name expunged (removed) from the State’s Central Registry. b. Consistent with RSA 169-C: 35, IV(c), I understand that as a result of this Petition to Expunge, the Court will order the Department to: (1) Submit my name, address, date of birth and social security number to the New Hampshire Department of Safety to conduct a search of their criminal records and for the results of this search to be submitted to the Court; (2) Report to the Court concerning any additi onal founded abuse and/or neglect reports against me; and (3) Provide any additional information that may aid the Court in making a determination on this Petition to Expunge. c. Attached is a signed and notariz ed Criminal Records Release. d. In addition to the above, I ask the Court to consider the following information in support of the Petition to Expunge: Case Name: Case Number: PETITION TO EXPUNGE NHJB-2135-DF (01/01/2011) Page 2 of 2 e. Upon the Court’s receipt and review of the information provided by the Department, I request that the Court grant this Petition to Expunge and order the Department to remove my name from the State’s Central Regist ry, OR, in the alternative, that the Court schedule a hearing on this Petition. Date Signature of Petitioner Printed Name of Petitioner State of , County of This instrument was ack nowledged before me on by My Commission Expires Affix Seal, if any Signature of Notarial Officer / Title THE COURT MAKES THE FOLLOWING ORDERS: DCYF shall submit the petitioner ’s name, address, date of birth and social security number to the New Hampshire Departm ent of Safety to conduct a search of their criminal records and for the results of this search to be submitted to the Court; DCYF shall report to the Court concerning any additional founded abuse and/or neglect reports against the petitioner; and DCYF shall provide any additional informati on that may aid the Court in making a determination on this Petition to Expunge. Other: Recommended: Date Signature of Marital Master Printed Name of Marital Master So Ordered: I hereby certify that I have r ead the recommendation(s) and agree tha t, to the extent the marital master/judicial referee/hearing officer has made fact ual findings, she/he has applied the correct legal standard to the facts determined by the marita l master/judicial referee/hearing officer. Date Signature of Judge Printed Name of Judge C: Petitioner Court NH DCYF, Central Registry Other: ORDER