SUPERIOR COURT OF CALIFORNIA, COUNTY OF RIVERSIDE RI-JV004 AGENCY (Name and Address) FOR COURT USE ONLY TELEPHONE NO.: E-MAIL ADDRESS (Optional): FAX NO. (Optional): CASE NAME: CASE NUMBER: ACKNOWLEDGEMENT OF JUVENILE RECORDS SEALED INSTRUCTIONS: Pursuant to WIC §§ 781 & 786, agencies shall advise the Court of its compliance with the sealing order. Please return the completed Acknowledgement of Juvenile Record Sealed form to the Riverside Superior Court. 1. TO THE CLERK OF THE COURT: I certify that the records ordered sealed by the court have been sealed, and a copy of the acknowledgement of record sealing has been sent to the court advising the court of compliance with its order. Date of Court Order: Child's Name: Agency Name: 2. 3. 4: Date: By: (TYPE OR PRINT YOUR NAME) (SIGNATURE) Page 1 of 1 Approved for Optional Use Riverside Superior Court RI-JV004 [Rev. 01/01/16] ACKNOWLEDGEMENT OF JUVENILE RECORDS SEALED WIC §§ 781 & 786 riverside.courts.ca.gov/localfrms/localfrms.shtml American LegalNet, Inc. www.FormsWorkFlow.com