|
STATE
OF In The General Court Of Justice District Superior Court Division ______________________County |
|
|||||||||
|
STATE VERSUS |
REQUESTS AND REPORTS CONVICTIONS/EXPUNCTIONS DISMISSALS AND DISCHARGE |
|
||||||||
|
Name
And Address Of Defendant (Type or Print) |
|
|||||||||
|
Race |
Sex |
DOB |
S.S.# |
Offense
To Be Expunged or Dismissed |
G.S.
No. |
|
||||
|
Relief
Requested And Statute Under Which Application Made (Check Only One) Expunction of records under: 15A-145 15A-146 90-96(b) 90-96(d) 90-96(e) 90-113.14(b)
90-113.14(d) 90-113.14(e) Dismissal of charges and discharge of
defendant under: 90-96(a) 90-113.14(a) |
|
|||||||||
|
|
OFFENSE INFORMATION |
|
|
DATE |
|
|||||
|
(Check And Give Date For All Which Apply) Date
Offense Committed |
|
|
||||||||
|
Date Of Arrest, Indictment Or Service Of Other Initiating Process |
|
|
||||||||
|
Date Of Dismissal Or Finding Of Not Guilty |
|
|
||||||||
|
Date Of Guilty Plea Or Date Found Guilty |
|
|
||||||||
|
Date Of Dismissal And Discharge Under G.S. 90-96(a) or G.S. 90-113.14(a) |
|
|
||||||||
|
Date Of Conviction |
|
|
||||||||
|
Name
And Address Of Arresting Agency |
Name
And Address Of Defendant’s Attorney |
|
||||||||
|
|
OFFENSE INFORMATION |
|
|
|||||||
|
I certify that an application under the statute identified above and all affidavits required under that statute have been filed in this case, that I have served copies on the district attorney, and that the information set forth above Is a complete and accurate statement of the information on file in the office of the Clerk of Superior Court. |
|
|||||||||
|
Date |
Signature |
Defendant |
|
|||||||
|
To The State Bureau
Of Investigation, Please prepare, certify on the reverse side, and attach to this Request any Criminal Record History Information for the petitioner. Then forward this request with Criminal Record History Information attached, confidentially to: Records Officer, Administrative Office of the Courts,
Courier Available, mail to: |
|
|||||||||
|
Date |
Name
Of Presiding Judge (Type Or Print) |
Signature
Of Presiding Judge |
|
|||||||
|
STATE
OF In The General Court Of Justice District Superior Court Division ______________________County |
||||||||||||
|
STATE VERSUS |
REQUESTS AND REPORTS CONVICTIONS/EXPUNCTIONS DISMISSALS AND DISCHARGE |
|||||||||||
|
Name
And Address Of Defendant (Type or Print) |
||||||||||||
|
Race |
Sex |
DOB |
S.S.# |
Offense
To Be Expunged or Dismissed |
G.S.
No. |
|||||||
|
Relief
Requested And Statute Under Which Application Made (Check Only One) Expunction of records under: 15A-145 15A-146 90-96(b) 90-96(d) 90-96(e) 90-113.14(b)
90-113.14(d) 90-113.14(e) Dismissal of charges and discharge of
defendant under: 90-96(a) 90-113.14(a) |
||||||||||||
|
|
OFFENSE INFORMATION |
|
|
DATE |
|
|||||||
|
(Check And Give Date For All Which Apply) Date
Offense Committed |
|
|||||||||||
|
Date Of Arrest, Indictment Or Service Of Other Initiating Process |
|
|||||||||||
|
Date Of Dismissal Or Finding Of Not Guilty |
|
|||||||||||
|
Date Of Guilty Plea Or Date Found Guilty |
|
|||||||||||
|
Date Of Dismissal And Discharge Under G.S. 90-96(a) or G.S. 90-113.14(a) |
|
|||||||||||
|
Date Of Conviction |
|
|||||||||||
|
Name
And Address Of Arresting Agency |
Name
And Address Of Defendant’s Attorney |
|||||||||||
|
|
OFFENSE
INFORMATION |
|
||||||||||
|
|
|
|
|
|
|
|||||||
|
|
||||||||||||
|
Date |
Name
of Presiding Judge (Type or print) |
Signature
of Presiding Judge |
||||||||||