Fill and Sign the State Attorney Section a Applicant Florida Department of Law Form

FLORIDA DEPARTMENT OF LAW ENFORCEMENT APPLICATION FOR JUVENILE DIVERSION EXPUNCTION PLEASE TYPE OR PRINT ALL INFORMATION Last Name First Name Middle Name FOR EXPUNCTION APPLICATIONS ONLY Other Names (Maiden Name or Alias) Residence Phone Business Phone ( ) ( ) Date of Birth (DOB) Race Sex Social Security No. MONTH DAY YEAR Mailing Address City State Zip Permanent Address City State Zip Arresting or Detaining Agency Date(s) of Arrest or Detention Date of Completion of Prearrest or Postarrest Diversion Program Charge(s) NOTARY (Signature of Parent or Guardian must be notarized if Applicant is under 18 years of age) 1. __________________________________________ Sworn to and subscribed before me 2. __________________________________________ This ______ Day of _______________, 20____________ ______________________________________________ I hereby certify that the information contained herein is true (Signature of Notary Public) and correct to the best of my knowledge. ________________________________________ ______________________________________________ (Print, Type, or Stamp Commissioned Name of Notary) Applicant Signature Date ______________________________________________ Personally Known ____ or Produced Identification _____ Parent/Legal Guardian Signature Date (Required if Applicant is under 18 years of age) Type of Identification Produced: ____________________ State Attorney County Circuit Reviewing Officer Charge(s) Description Statute Violation Case Number Action 1. ___________________________________ ___________________ _________________ _________________ 2. ___________________________________ ___________________ _________________ _________________ 3. ___________________________________ ___________________ _________________ _________________ 4. ___________________________________ ___________________ _________________ _________________ ________________________________________________ ___________________________________________________ Signature Title (Prosecuting Authority Date (Month) (Day) (Year) Acct/Budget Expunge Section Expunge Section Date Received __________________ I.D.# ________________ORI _______________ Date Received __________________ Check _________________________ Appl ication Status Approved Denied Date Entered ___________________ Processed By ___________-_______ Expunge Date Mailed ____________________ FDLE 40-025, pursuant to Rule 11C-7.009(1)(b) Revised February 2008 SECTION B – STATE ATTORNEY SECTION C FDLE I certify that the person named above has successfully completed a prearrest or postarrest diversion program in the above-named County as authorized by s.985.3065, that participation in this program is strictly limited to minors arrested for a nonviolent misdemeanor (as that term is defined in s.943.0582) , and that to my knowledge and based on the information available to me this person has not otherwise been charged with or foun d to have committed any criminal offense or comparable ordinance violation. Therefore, pursuant to s.943.0582, this person is eligible to have his or her criminal history record expunged with the intent of and as limited by s.943.0582. Date of completion of prearrest or postarrest diversion program (To be filled in by Prosecuting Authority) SECTION A – APPLICANT INSTRUCTIONS PLEASE TYPE OR PRINT ALL INFORMATION GENERAL INFORMATION: The laws and rules, which govern juvenile diversion expunction of criminal history record(s), include: Section 943.0582, Florida Statutes, and Chapter 11C-7009, Florida Administrative Code. *For authorized juvenile diversion programs complete d on or after October 1, 2001, the law requires the application to be submitted to FDLE no later than six months after completion of the diversion program. THIS IS AN APPLICATION FORM FOR JUVENILE DIVERSION EXPUNCTION (F.S. 943.0582) WHICH IS AN ADMINISTRATIVE PROCESS AND IS COMPLETED BY TH E AGENCIES CONCERNED. IT DOES NOT REQUIRE FILING A PETITION WITH THE COURT, AND DOES NOT REQUIRE OR AUTHORIZE THE ISSUANCE OF A CERTIFICATE OF ELIGIBILITY BY FDLE. PLEASE CONSULT THE APPLICABLE LAW OR SEEK LEGAL ADVICE IF YOU ARE UNCERTAIN OF THE DIFFERENCES BETWEEN JUVENILE DIVERSION EXPUNCTION AND COURT- ORDERED EXPUNCTION (F.S. 943.0585). (SECTION A) APPLICATION INFORMATION In order to obtain a juvenile diversion expunction of a criminal history record, the following documents must be provided to the FDLE pursuant to s. 943.0482, F.S. 1. Complete the reverse side of this application. Section A must be completed by the applicant and signed by the applicant or the applicant’s parent or legal guardian if the applicant is under 18 years of age at the time of signing, and the applicable signature must be notarized. 2. A NONREFUNDABLE money order, Cashier’s check, or a personal check in the amount of $75.00 made payable to the Florida Department of Law Enforcement. 3. The applicant must be fingerprinted by authorized personnel with a law enforcement or criminal justice agency. The enclosed FDLE Applican t Fingerprint card FD 258 must be used. 4. You must have the state attorney complete Sectio n B, on the reverse side of this application, certifying that you have successfully completed a prearrest or postarrest diversion program that allows for the expunction of the record upon completion as authorized by s. 943.0582, F.S. 5. You should be aware that eligibility for a juvenile diversion expunction is conditioned upon timely and successful completion of a prearrest or postarrest diversion program authorized by s. 985.3065, F.S., which program must be limited to first-ti me minor offenders charged with a nonviolent misdemeanor as the term “nonviolent misdemeanor” is defined in s. 943.0582, F.S.. You should also be aware that the term “expunction” as used in s. 943.0582, F.S., differs significantly in operation and effect from term “expunction” as used in s.943.0585, F.S. (SECTION B) STATE ATTORNEY INOFRMATION ONLY: Section 943.0582, Florida Statutes, states that an applican t seeking a juvenile diversion expunction of a criminal history record must be obtain an official written statem ent from the appropriate state attorney as reflected in Section B on the reverse side of this form. (SECTION C) (TO BECOMPLE TED BY THE FDLE ONLY) MAILING INSTRUCTIONS: Once you have completed all applicable requirements as stated above, mail this application, all documents, and the $75.00 processing fee to: The Florida Department of Law Enforcement Attn: Expunge/Seal Section Post Office Box 1489 Tallahassee, Florida 32302-1489 If the application is not complete and all of the nece ssary documents are provided, the FDLE will return your package unprocessed. Any questions should be directed to the FDLE’s Expunge Section at (850) 410-7870. FINGERPRINTS FOR APPLICATION FOR JUVENILE DIVERSION EXPUNCTION Name: Last______________________________ First _______________________Middle _________________________ Alias(aka) Name: Last_______________________ First _______________________Middle _________________________ RACE: __ SEX:___ DOB: ______ * SOCIAL SECURITY NUMBER (SOC): __________________________ Please mail completed application and fingerprints to: FDLE, P.O. Box 1489, Tallahassee, FL 32302, Attn: Expunge/Seal Section Signature of official taking fingerprints: _____________________________________ ORI: ________________________________ Signature of person fingerprinted: ________________________________ Date: ________________________________________ 1. R. Thumb 2. R. Index 3. R. Middle 4. R. Ring 5. R. Little 6. L. Thumb 7. L. Index 8. L. Middle 9. L. Ring 10. L. Little Left Four Fingers Taken Simultaneously L. Thumb R. Thumb Right Four Fingers Taken Simultaneously • This information is voluntary, failure to disclose may delay the processing time of your application. Form 40-024 DID YOU REMEMBER TO… … Complete the application? Did you Sign and date the application in front of a notary? … Provide a certified (stamped copy) disposition of your case you want to have sealed/expunged? … Include your name, race/sex, date of birth, social security number and signature on the fingerprint form? … Provide a $75.00 check or money order made payable to FDLE? Did you sign and completely fill out the check or money order? … Include an Attorney’s letter head, if you (applicant) are represented by an attorney? … Make copies of your application and documents for your records? … For Expunge Applicants only: Is Section B completed and signed by the State Attorney’s Office? … For Juvenile Expunge Applicants only: Is Section B completed and signed by the State Attorney’s Office? FDLE asks that you provide your social security number (SSN). The decision to provide your SSN is at your option, and if you provide your SSN, FDLE will use it for purposes of identification, and may share the information with other agencies for the same purpose. FDLE’s request for your SSN is authorized by state law because use of it is imperative for FDLE to fulfill its lawful duties and responsibilities. Your failure to provide your SSN may result in a delay in processing your application or request.