þ þ The State of Michigan THE PEOPLE OF þ þ 1. þ On en-USDateen-US I was convicted of en-USOffenseen-US . en-USA certified copy of the conviction is attached. 2. þ I en-USrequesten-US that the court issue an order to set aside the above conviction as provided by law. I consent to use of the nonpublic þ record created by MCL 780.623 to the extent authorized by MCL 780.623. 3. þ þ No other application has been filed to set aside this conviction. en-USOR þ þ An application was previously filed to set aside this conviction on en-USDateen-US . The application was disposed þ þ of as follows: en-US en-US . þ 4. þ þ No other application has been filed to set aside another conviction. en-USOR þ þ An application was previously filed in þ þ this court þ þ the en-US en-US Court to set aside a þ conviction for en-US en-US , in addition to the conviction in item 1. The application was disposed þ of as follows: en-US en-US . 5. þ At least five years have passed since sentence was imposed or discharge from imprisonment, probation, or parole for this þ þ conviction, whichever is later. 6. þ þ I have not had any convictions deferred and dismissed. þ þ I have had the following conviction(s) deferred and dismissed: þ þ en-US en-US . 7. þ þ There are no other criminal charges pending against me. þ þ There are criminal charges pending against me in the þ en-US en-US Court, case number en-US en-US . 8. þ I have not been convicted of more than one felony and two misdemeanors as defined in MCL 780.621. þ en-USApplicant Signature þ þ en-USSubscribed and sworn to before me on en-USDateen-US , en-US en-US County, Michigan.en-USMy commission expires: en-USDateen-US Signature: en-USDeputy clerk/Notary publicen-USNotary public, State of Michigan, County of en-US American LegalNet, Inc. www.FormsWorkFlow.com Case No. en-USTO: Michigan Attorney General and en-USProsecuting officialen-USA hearing will be held on the above application to set aside conviction on en-USDateen-US at en-USTimeen-USat en-USLocationen-US before Judge þ Bar no. en-US .en-USI certify that copies of this application, certified record of conviction, and notice of hearing were served on theen-US þ prosecuting official on en-USDateen-US by first-class mail addressed to the last-known address.en-US þ Attorney General on en-USDateen-US by first-class mail addressed to the last-known address.en-USI certify that copies of this application, certified record of conviction, and the fingerprint card, accompanied by the required fee, wereen-USserved on the Michigan State Police on en-USDateen-US by first-class mail addressed to the last-known address. en-USDate þ en-USApplicant/Attorney signatureen-USINSTRUCTIONS:en-USFor additional instructions and an online interview that will help you create forms, go to michiganlegalhelp.org. 1. þ Determine whether you are eligible to apply to have your conviction set aside according to MCL 780.621. You must complete þ a separate application for each conviction if you are applying to have more than one conviction set aside. 2. þ Find out the exact date of conviction and the charge from the court. Get a certified copy of the adjudication and attach it to þ your application. 3. þ Swear to the truth of the statements in this application and then sign it in the presence of the court clerk or a notary public. 4. þ Make four copies of all attachments and this application. Take all copies to the court clerk. 5. þ Depending on local practice, the clerk of the court may set a hearing date at the time of filing. If a hearing date is set at the þ time of filing, the clerk of the court will complete the Notice of Hearing. 6. þ Go to the local law enforcement agency for a fingerprint card and get fingerprinted on the applicant card (RI-8). There may þ be a fee for fingerprinting. Fill out the card completely. 7. þ Make out a money order or check to the State of Michigan for the application. The application fee is $50.00. This fee is sent þ with the application packet to the Michigan State Police for processing. 8. þ Mail a copy of the application packet, application fee, and the fingerprint card to the Michigan State Police by first-class mail þ to Michigan State Police, Criminal Justice Information Center - Criminal History, PO Box 30266, Lansing, Michigan 48909. 9. þ Mail a copy of the application packet to the Attorney General of the State of Michigan by first-class mail to Office of the þ þ Attorney General, Criminal Appellate Division, PO Box 30217, Lansing, Michigan 48909. 10. þ Mail a copy of the application packet to the correct prosecuting official where the conviction occurred (county, city, or þ þ township) by first-class mail. See www.michiganprosecutor.org/about-us-menu/prosecutor-directory for the addresses of þ county prosecutors. 11. þ On both copies of the application, fill in the Proof of Service on the back of the form. After you fill out and sign the Proof of Service, þ mail or take one of the remaining application packets with the completed Proof of Service to the court. Keep the other copy þ of the application packet for your records. en-USNOTICE OF HEARING en-USPROOF OF SERVICE en-USThe hearing cannot be held until the court receives the en-USMichigan State Police report required by MCL 780.621(9). American LegalNet, Inc. www.FormsWorkFlow.com