Petition to Expunge and Impound Criminal Records (01/20/17) CCCR 0330 A IN THE CIRCUIT COURT OF COOK COUNTY, ILLINOIS PEOPLE OF THE STATE OF ILLINOIS or _________________________________________________ A Municipal Corporation v. ___________________________________________________ Defendant/Petitioner No. _______________________________________________ _______________________________________________ _______________________________________________ _______________________________________________ _______________________________________________ Date of Birth: ___________________ Gender: Male Female Race: _________________________ PETITION TO EXPUNGE AND IMPOUND CRIMINAL RECORDS - FEE REQUIRED The above-named Petitioner states under oath that: 1. The Petitioner was arrested and/or charged on the date(s) and for the offense(s) stated below: Case Number(s) Arresting Agency(ies) Charge(s) Date(s) of Arrest SID/IR/DCN/CB Disposition Additional cases listed on attached page. Petitioner's Address: _______________________________________________________________________ _______________________________________________________________________________________ 2. Each arrest or charge not initiated by arrest, other than a minor traffic offense resulted in a. an order of supervision was successfully completed for an offense that is subject to expungement and the requisite time period has elapsed. b. an order of qualified probation was successfully completed for an offense that is subject to expungement and the requisite time period has elapsed and the Petitioner has attached proof to this Petition that s/he has passed a drug test taken within 30 days before the filing of this Petition showing the absence within his or her body of all illegal substances; and/or c. The Petitioner was granted a pardon by the Governor which specifically authorizes expungement. 3. The Petitioner does not have pending charges against him/her. DOROTHY BROWN, CLERK OF THE CIRCUIT COURT OF COOK COUNTY, ILLINOIS Page 1 of 2 Petition to Expunge and Impound Criminal Records (01/20/17) CCCR 0330 B The relief should be granted for the following reason(s): _________________________________________________________________________________________ _________________________________________________________________________________________ WHEREFORE, the Petitioner asks the Court to expunge and impound his/her arrest records and return the expunged records to Petitioner at the address shown above (or at the address updated by the Petitioner with the Clerk of Court as required by 20 ILCS 2630/5.2(d)(2). Under penalties as provided by law pursuant to Section 1-109 of the Code of Civil Procedure, 735 ILCS 5/1-109, the undersigned certifies that the statements set forth in this instrument are true and correct, except as to matters therein stated to be on information and belief and as to such matters the undersigned certifies as aforesaid that s/he verily believes the same to be true. Dated: _________________________________ ________________________________________ Defendant/Petitioner Prepared by: _________________________________________ Cook County Attorney Code: ____________________________ Address: _____________________________________________ City/State/Zip: ________________________________________ Telephone: ___________________________________________ Primary Email: _______________________________________ Secondary Email: ______________________________________ Tertiary Email: ________________________________________ Received this day ________of _______________ _______________________________________ (State's Attorney/Prosecutor/ISP/Arresting Agency/ Chief Local Government Legal Office) DOROTHY BROWN, CLERK OF THE CIRCUIT COURT OF COOK COUNTY, ILLINOIS Page 2 of 2