X COUNTY, PENNSYLVANIA CRIMINAL DIVISION VS. <ClientFullName> PID: <PP> SID: <SID> : <DocketNo> : <RelatedDockets> ORDER

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1 COMMONWEALTH OF PID: <PP> SID: <SID> : <RelatedDockets> ORDER AND NOW, this day of, 2018, after consideration of the expungement presented <Attorney Name> it is ORDERED that the Petition/Motion is granted. The criminal charges in the above-captioned case specified below are <Disposition>. The defendant s arrest record regarding these charges shall be expunged. Further, it is ORDERED that the arresting agency shall destroy all criminal records, fingerprints, photographic plates and photographs pertaining to the charge(s) specified below, which resulted from the arrest(s) of <ArrestDt>. In addition, all criminal justice agencies upon which this order is served shall expunge and destroy the official and unofficial arrest and other criminal records, files and other documents pertaining to the captioned proceedings. The information required under Pa.R.Crim.P. 790 appears on the attached page(s) which is hereby incorporated into this ORDER by reference. BY THE COURT: J.

2 Pursuant to Pa.R.Crim.P. 790, the following information is provided: 1. Petitioner Name: 2. Alias(es): <Aliases> 3. Petitioner s Address: <AddressLn1>, <AddressLn2>, <City>, <StateCode> <Zip> 4. Petitioner s Date of Birth: <DOB> 5. Petitioner s Social Security#: <SSN> 6. Name and address of the judge of the Court of Common Pleas or X Municipal Court who accepted the guilty plea or heard the case: Judge <JudgeName> <Courthouse Address> 7. Name and mailing address of the affiant as shown on the complaint, if available: <Affiant> <Mailing Address> 8. Docket Number, <RelatedDockets> 9. Offense Tracking Number (OTN): <OTN> 10. The date on the complaint, or the date of arrest, and if available, the criminal justice agency that made the arrest: Arrest Date: <ArrestDt> Made by the X Police Department 11. The specific charges, as they appear on the charging document, to be expunged and applicable dispositions (attach additional sheets if needed): <_ChargesStatute> 12. If the sentence includes a fine, costs, or restitution, whether the amount due has been paid: <FineRestitutionPaid> 13. The reason for expungement: <ReasonForExpungement> 14. The criminal justice agencies upon which certified copies of the order shall be served: a. X Police Department, Expungement Unit b. Pennsylvania State Police, Central Records c. A.O.P.C., Expungement Unit

3 COMMONWEALTH OF <AddressLn1>, <AddressLn2> <City>, <State> <Zip> : PP# <PP> : SS# <SSN> : DOB: <DOB> : <RelatedDockets (If any)> : OTN# <OTN> PETITION TO EXPUNGE CRIMINAL RECORD TO THE HONORABLE, THE JUDGES OF THE SAID COURT: represents: Petitioner,, by <HisHer> counsel, <Attorney Name>, respectfully 1. Petitioner lives <AddressLn1>, <AddressLn2>, <City>, <State> <ZipCode> and is <AgeInYears> years old; date of birth is <DOB>. <Charges>. <Disposition>. 2. Petitioner was arrested by the X Police Department on <ArrestDt>, and charged with 3. On <DispoDt>, before Judge <JudgeName> on <DocketNo>, the charges were 4. As a result of this arrest and subsequent photographing and fingerprinting, petitioner has been caused to suffer embarrassment and irreparable harm. 5. The Commonwealth of Pennsylvania will not be harmed by granting this petition. WHEREFORE, your petitioner prays that the Court direct the Commissioner of the X Police Department and the Commissioner of Pennsylvania State Police to expunge the fingerprints, photographs and records of the arrest(s) of petitioner from the files of their respective Police

4 Departments and deliver the same to your petitioner or their attorney, or in lieu thereof, proof that said data has been destroyed and that he request that the Federal Bureau of Investigation return all records pertaining to the same arrest(s) for destruction by the X Police Department or by petitioner, and further, the Administrative Office of Pennsylvania Courts (AOPC) in Mechanicsburg, PA, have the same records removed from the Court computer indexes. RESPECTFULLY SUBMITTED, Attorney Name

5 COMMONWEALTH OF <AddressLn1>, <AddressLn2> <City>, <State> <ZipCode> : PP# <PP> : SS# <SSN> : DOB: <DOB> : <RelatedDockets> : OTN# <OTN> VERIFICATION The facts set forth in the foregoing are true and correct to the best of the undersigned s knowledge, information and belief and are verified subject to the penalties for unsworn falsification to authorities under Title18, ~4904 of the Pennsylvania Crimes Code. Date Attorney Name