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FACTS PERTAINING TO EXPUNGEMENT MATTER ________: ☐ CONVICTION FOR A MISDEMEANOR☐ CONVICTION FOR A __________ FELONY THAT WAS REDUCED TO A

MISDEMEANOR

1. Petitioner was arrested in _______________________ County on __________________ by_________________________ employed by the law enforcement agency known as _____________________________under law enforcement agency case number _________________________;

2. Petitioner was convicted on the following charges on _____________________________, under Cause Number________________________________ in __________________ _________________ Court, Criminal Division,Room__________.

Title Class/Level Count Category a. b. c. d.

☐ Said felony judgement was converted to a class A misdemeanor on __________________________.

3. Petitioner is not a person who is prohibited from seeking this remedy under the provisions of I.C. §35-38-9-2(b).

4. Elapsed time:☐ Five (5) years have passed between the date of Petitioner’s conviction and the filing of this Petition.☐ Fewer than five (5) years have passed between the date of Petitioner’s conviction and the filing of this Petition,

but the ____________________ County Prosecuting Attorney has provided written consent for a shorter elapsedtime period (see Exhibit _____ attached, letter of consent from __________________________ CountyProsecutor).

5. Criminal activity within the previous five (5) years:☐ Petitioner affirms that to the best of their knowledge, they have not committed another crime in any jurisdiction

within the previous five (5) years.☐ Petitioner affirms that, to the best of their knowledge, they have not committed another crime in any jurisdiction

within the shorter elapsed time period to which the prosecuting attorney has agreed.

6. Petitioner has:☐ Paid all fines, fees, and court costs, and no restitution obligation was imposed as part of their sentence☐ Satisfied their restitution obligation of $_____________________ imposed as part of their sentence.☐ Been found indigent as to all outstanding fines, costs, and fees ordered as part of the sentence.

7. Appellate activity:☐ The case that Petitioner is requesting be sealed has not been appealed.☐ The case that Petitioner is requesting be sealed was appealed on ______________________ under the

following appellate cause number _____________________________.

8. Related MC cause numbers:☐ Court records stored under the following MC case/cause numbers constitute records of the sentencing court or

juvenile court for the purposes of this order:____________________________________________________________________________________________________________________________________________________________________________________

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NOT PUBLIC RECORD

FINDINGS PERTAINING TO EXPUNGEMENT MATTER ________: ☐ CONVICTION FOR A MISDEMEANOR☐ CONVICTION FOR A __________ FELONY THAT WAS REDUCED TO A

MISDEMEANORThe Court now finds by a preponderance of the evidence that:

1. Petitioner’s verified petition for expungement seeks relief as provided by I.C. §35-38-9-2 for a convictionentered on the following changes on ____________________________, under Cause Number______________________________________ in __________________ _________________, Criminal Division,Room ___________.

Title Class Count Category a. b. c. d.

☐ Said felony judgement was converted to a class A misdemeanor on __________________________.

2. Petitioner is not a person who is prohibited from seeking this remedy under the provisions of I.C. §35-38-9-2(b).

3. Elapsed time:☐ Five (5) years have passed between the date of Petitioner’s conviction and the filing of this Petition.☐ Fewer than five (5) years have passed between the date of Petitioner’s conviction and the filing of this Petition,

but the ____________________ County Prosecuting Attorney has provided written consent for a shorter elapsedtime period (see Exhibit _____ attached, letter of consent from __________________________ CountyProsecutor).

4. Criminal activity within the previous five (5) years:☐ Petitioner affirms that to the best of their knowledge, they have not committed another crime in any jurisdiction

within the previous five (5) years.☐ Petitioner affirms that, to the best of their knowledge, they have not committed another crim in any jurisdiction

within the shorter elapsed time period to which the prosecuting attorney has agreed.

5. Petitioner has:☐ Paid all fines, fees, and court costs, and no restitution obligation was imposed as part of their sentence☐ Satisfied their restitution obligation of $_____________________ imposed as part of their sentence.☐ Been found indigent as to all outstanding fines, costs, and fees ordered as part of the sentence.

6. Appellate activity:☐ The case that Petitioner is requesting be sealed has not been appealed.☐ The case that Petition is requesting be sealed was appealed on ______________________ under the following

appellate cause number _____________________________.

7. Related MC cause numbers:☐ Court records stored under the following MC case/cause numbers constitute records of the sentencing court or

juvenile court for the purposes of this order:____________________________________________________________________________________________________________________________________________________________________________________

The court now finds that the Petition as to EXPUNGEMENT MATTER ______ shall be GRANTED. NOT PUBLIC RECORD

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NOT PUBLIC RECORDEXHIBIT _______, Page _____ of _________:

FINDINGS AND ORDER GRANTING PETITION FOR EXPUNGEMENT OF CONVICTION RECORDS PURSUANT TO I.C. §35-38-9 (XP Cause Number: ________________________________________)

EXPUNGEMENT MATTER _______,

PETITIONER IDENTIFICATION INFORMATION:

Full Name: ____________________________________ Alias Names, DOBs and SSNs: DOB: ________________________________________ ______________________________________ SSN: ________________________________________ ______________________________________

______________________________________ Addresses since first criminal offense addressed in this Order: ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________

INDIVIDUAL ARREST INFORMATION: Criminal Cause Number: _______________________________________ ________________________________________________________________________________________________________________________________________________________________________________________________

Arresting Agency: ____________________________________________ County/City of Arrest: _________________________________________ Law Enforcement Agency Case Number: __________________________

Date of Arrest: ____________________ Date of Conviction: ______________________

List of Charges: Disposition of Charges:

☐ Expunged pursuant to I.C. § 35-38-9-6

☐ Expunged pursuant to I.C. § 35-38-9-7

☐ NOT expunged

NOT PUBLIC RECORD