THE STATE OF NEW HAMPSHIRE JUDICIAL BRANCH http://www.courts.state.nh.us Court Name: Case Name: Case Number: (if applicable) PETITION TO EXPUNGE (REMOVE) Pursuant to RSA 169-C:35 1. Petitioner Name Date of Birth Residence Address Mailing Address (if different) Telephone Number (Home) 2. 3. 4. Social Security Number (Work) Date of Birth Child's Name Date of Court Finding (if applicable) The petitioner states as follows: a. Pursuant to RSA 169-C:35, my name was listed as reported by the New Hampshire Department of Health and Human Services, Division for Children, Youth and Families ("the Department") as of (date) on the State's Central Registry of founded reports of abuse and neglect. It has been: More than one (1) year since the date my name was entered on the State's Central Registry; OR Three (3) or more years since the denial of my last Petition to have my name expunged (removed) from the State's Central Registry. b. Consistent with RSA 169-C:35, IV(c), I understand that as a result of this Petition to Expunge, the Court will order the Department to: (1) Submit my name, address, date of birth and social security number to the New Hampshire Department of Safety to conduct a search of their criminal records and for the results of this search to be submitted to the Court; (2) Report to the Court concerning any additional founded abuse and/or neglect reports against me; and (3) Provide any additional information that may aid the Court in making a determination on this Petition to Expunge. c. d. Attached is a signed and notarized Criminal Records Release. In addition to the above, I ask the Court to consider the following information in support of the Petition to Expunge: NHJB-2135-DF (01/01/2011) Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com Case Name: Case Number: PETITION TO EXPUNGE e. Upon the Court's receipt and review of the information provided by the Department, I request that the Court grant this Petition to Expunge and order the Department to remove my name from the State's Central Registry, OR, in the alternative, that the Court schedule a hearing on this Petition. Date Signature of Petitioner Printed Name of Petitioner State of This instrument was acknowledged before me on My Commission Expires Affix Seal, if any , County of by Signature of Notarial Officer / Title ORDER THE COURT MAKES THE FOLLOWING ORDERS: DCYF shall submit the petitioner's name, address, date of birth and social security number to the New Hampshire Department of Safety to conduct a search of their criminal records and for the results of this search to be submitted to the Court; DCYF shall report to the Court concerning any additional founded abuse and/or neglect reports against the petitioner; and DCYF shall provide any additional information that may aid the Court in making a determination on this Petition to Expunge. Other: Recommended: Date Signature of Marital Master Printed Name of Marital Master So Ordered: I hereby certify that I have read the recommendation(s) and agree that, to the extent the marital master/judicial referee/hearing officer has made factual findings, she/he has applied the correct legal standard to the facts determined by the marital master/judicial referee/hearing officer. Date Signature of Judge Printed Name of Judge C: Petitioner Court NH DCYF, Central Registry Other: NHJB-2135-DF (01/01/2011) Page 2 of 2 American LegalNet, Inc. www.FormsWorkFlow.com