Fill and Sign the S Official Use Only Form

PETITION AND ORDER OF EXPUNCTIONUNDER G.S. 15A-149 (PARDON OF INNOCENCE) G.S. 15A-149, 15A-150 Name And Address Of Petitioner (type or print full name) STATE VERSUS Full Social Security No. Drivers License No. StateRace Sex Date Of Birth Name And Address Of Petitioner’s Attorney For Expunction Petition NOTE TO PETITIONER: List the arresting agency and any State or local government agency that \ has a record of your case. You must provide complete information for each agency. The clerk of superior court will send a cop\ y of this order, if granted, to the agency name(s) and address(es) provided below. The clerk will not provide addresses for you. Do not list the courts, the State Bureau of \ Investigation, the Department of Public Safety, or the Division of Motor Vehicles; if the order is granted, those agencies will be notified autom\ atically. Do not list any private entity, like a company that provides criminal background checks. The clerk will not send a copy of this order to any entity that \ is not an agency of the State of North Carolina or one of its local governments. A private entity required to expunge records will be notified directly by the Stat\ e or local agencies that distribute criminal justice information to that entity. Check here to indicate that additional agencies are identified on an att\ achment to this petition. NOTE: The attachment must include the county, file number(s), the name of the petitioner, and a statement that it is a list of additio\ nal agencies with a record of the case(s) to be expunged. STATE OF NORTH CAROLINA County File No. Scan No.(s) (Official Use Only) Name And Address Of Arresting Agency Name And Address Of Other Agency (if any)Name And Address Of Other Agency (if any) In The General Court Of Justice District Superior Court Division PETITION TO EXPUNGE Date Signature Of Presiding Judge Name Of Presiding Judge (type or print) I certify that in this court of the county named above I was convicted o\ f a misdemeanor or a felony, the file number(s) for which is/are set o\ ut above. I further certify that I received a pardon of innocence from the Governor \ and there is filed in the office of the clerk of superior court in the c\ ounty in which I was convicted an attested copy of the pardon warrant and return for the \ offense(s) referenced above in accordance with G.S. 147-25. Therefore, pursuant to G.S. 15A-149, I hereby petition the Court to orde\ r the expunction from all official records any entries relating to my ap\ prehension, charge, or trial. The Court hereby FINDS that the petitioner 1. has received a pardon of innocence pursuant to G.S. 147-25, and the peti\ tion is therefore granted. The Court ORDERS: a. Any and all entries relating to the petitioner’s apprehension, charge\ or trial shall be expunged from all official records of the court. b. All law enforcement agencies, the Division of Adult Correction and Juven\ ile Justice of the Department of Public Safety, the Division of Motor Vehicles, and any other State or local government agency identified abov\ e and on any attachment to this petition are hereby directed to expunge \ from all official records any entries relating to the person’s appreh\ ension, charge, or trial. c. The costs of expunging records in compliance with this Order shall not b\ e taxed against the petitioner. 2. has not received a pardon of innocence pursuant to G.S. 147-25, and the \ petition is therefore denied. NOTE TO CLERK: If denied, file this Order in the case file. Upon expiration of the deadline for appeal from a denial of this Order, destroy any documentation provided with the petition, such as a criminal history report and any NCAOC report of prior expunctions. If granted, send a certified copy of this Order to the petitioner at the address listed above or an updated address as provided by the petitioner. I hereby verify that an attested copy of the warrant and return granting\ a pardon of innocence to the petitioner pursuant to G.S. 147-25 has been filed in the above-captioned case(s), and a copy is attached \ to this petition. has not been filed in the above-captioned case(s). FINDINGS AND ORDER VERIFICATION OF PARDON (Over) File No.(s) Date Of OffenseDisposition Offense Description Name (type or print) Date Signature Date Name (type or print) Dep. CSC Asst. CSC Clerk Of Superior Court Signature Petitioner Petitioner’s Attorney AOCC5, 5ev. ,