ATTORNEY OR PARTY WITHOUT ATTORNEY (NAME AND ADDRESS): TELEPHONE NO.: FOR COURT USE ONLY ATTORNEY FOR (NAME): SUPERIOR COURT OF CALIFORNIA, COUNTY OF SANTA BARBARA STREET ADDRESS: MAILING ADDRESS: CITY AND ZIP CODE: BRANCH NAME: PLAINTIFF: People of the State of California DEFENDANT: ____________________________________________________________ PRINT OR TYPE DEFENDANTS NAME DECLARATION AND APPLICATION BY DEFENDANT PENAL CODE § 1210.1(d) 1. 2. 3. 4. CASE NUMBER: My date of birth is ________________________________. My driver's license number is ______________________________. On the date of __________________________________________, I was convicted of the offense(s) of violation of section(s) ______________________________________________________________________________________________. I was placed on probation, and I have fulfilled all the conditions of probation for the entire time required. All fines/fees to the Court and Provider are paid in full. I am not now charged with, serving a sentence for, or on probation for any offense. Since being placed on probation in this case, I have lived an honest life, have conformed to and obeyed the laws of the land, and have not been convicted, arrested, or given a citation (ticket) except _______________________________________________________________________________________________________. I request that the conviction be set aside, that a plea of not guilty be entered, and that the Court dismiss this action pursuant to the provisions of section 1210.1(d) of the Penal Code. I understand that if the court finds that I have successfully completed drug treatment and complied with the conditions of probation, and that the conviction is set aside and the action is dismissed, and that except as noted below, both the arrest and the conviction shall be deemed never to have occurred. The requested dismissal: (a) does not allow me to own, possess, or have in my custody or control any firearm capable of being concealed upon my person or prevent my conviction under section 12021, (b) will not prevent this conviction from being pleaded and proved in any subsequent prosecution, and (c) will not relieve me of the obligation to disclose the conviction in response to a direct question in any questionnaire or application for public office, for a position as a peace officer as defined by Section 830, for licensure by any state or local agency, or for contracting with the California State Lottery, or for purposes of serving on a jury. 5. 6. I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct. Signed on ___________________________________________ at ___________________________________________, California. Date Place Signature of Defendant Print or Type Defendant's Name Street Address City State Zip Code CII and DMV cleared on ________________________________ by _____________________________________ Date Deputy Clerk ORDER The declaration and application by defendant is Granted Pursuant to Penal Code section 1210.1(d), it is so ordered that the conviction be set aside, a plea of not guilty be entered, and the indictment, information, or complaint dismissed. Denied ____________________________________________________________________________________________ Dated: __________________________________ SC-3038 [Rev. Oct. 18, 2002] __________________________________________________ Judge of the Superior Court American LegalNet, Inc. www.USCourtForms.com DECLARATION AND APPLICATION BY DEFENDANT PC 1210.1(d)