This form is approved by the Illinois Supreme Court and is required to be accepted in all Illinois Circuit Courts. Page 1 of 4 STATE OF ILLINOIS, REQUEST TO EXPUNGE & IMPOUND AND/OR SEAL CRIMINAL RECORDS For Court Use Only CIRCUIT COURT COUNTY Instructions Request of: Enter your name, birth date, race, and gender. List any other names you used when arrested on the cases listed on this form. Your name (First, middle, last name) Other names used in these cases If the Clerk gave you a new case number, enter it to the right. Date of birth Race Gender Case Number (if the Clerk assigns a new number) Arrest or Case Numbers of all Eligible Criminal Offenses on your Record in this County: Enter the number for all eligible arrests and charges on your criminal record in this county. If an arrest did not result in formal charges, enter the arrest number. IF YOU ARE ONLY REQUESTING TO SEAL CASES, DO NOT FILL OUT SECTIONS 2 - 11. GO TO SECTION 12. 1. I am requesting to expunge and impound records. Yes No (If no, go to Section 1) 2 . I ask the Court to EXPUNGE AND IMPOUND the following arrests or charges from the records of the Arresting Agency, the Circuit Clerk, and the Illinois State Police. I was arrested, or charged without being arrested, and not convicted on the dates and for the offenses listed below: See How to Expunge and/or Seal a Criminal Record to make sure all of your cases can be erased by expunging your record. For help filling out this table, see pages 12 226 15. Do not list any convictions in this section. Arrest or Case Number Arresting Agency Charge ( list all charges for each case number ) Date of Arrest Outcome (for example, RV, S or P) In 2, enter all eligible arrests or charges on your record. Enter all charges for each case number. For Outcome, enter an outcome that matches the outcome of your case. Use the shortened version of the outcome from the Outcome Abbreviation s box. Outcome Abbreviations RV Conviction R eversed or V acated P Pardon from the Governor C E Certificate of Eligibility for Expungement from PRB FI Found Factually I nnocent If you need more room, use the Additional Arrests or Cases for Expungement form and check the box. RWC Released W ithout C harge DA Dismissal or A cquittal S Supervision Successfully Completed QP Qualified Probation Successfully C ompleted I have listed additional arrests or cases on the attached Additional Arrests or Cases for Expung e ment form. American LegalNet, Inc. www.FormsWorkFlow.com Enter the Case Number given by the Circuit Clerk: Page 2 of 4 In 3-11, check ALL boxes that apply. 3 . I was not convicted of any offenses I want to expunge, unless ( C heck the box that applies) : a. I was convicted, but the conviction was reversed or vacated; OR In 3, you cannot expunge a criminal conviction unless one of the special situations listed under checkboxes a, b, c, or d describes your case. b. I received a p ardon from the Governor of the State of Illinois allowing expungement. ( A ttach a copy of the pardon . ) ; OR c. I received a Certificate of Eligibility for Expungement by the Prisoner Review Board. ( A ttach a copy of the Certificate . ) ; OR d. I was found factually innocent in the case I am asking to expunge. 4 . F or at least one case, I was arrested and released, and no charges were filed against me . 5 . For at least one case, I was arrested for a minor traffic offense and released from custody without being charged. 6 . For at least one case, I was charged, but was later acquitted, or released without In 7, your record must specifically state that you had Qualified Probation. It might also be called Second Chance, 410, 710, 1410, or TASC probation. being convicted. 7 . For at least one case, I received a sentence of Qualified Probation ; AND a. At least 5 years have passed since my Qualified Probation ended s uccessfully ; AND b. I have attached the results of a drug test that I passed within the last 30 days. 8 . For at least one case, I received a sentence of s upervision; AND In 8 , if you got supervision for any case, 5 years must have passed since the end of the sentence for: Domestic Battery;Criminal SexualAbuse;Driving withoutInsurance;Driving with registration suspended for Non-Insurance;Display of FalseInsurance Card;Scrap Processors toKeep Records; OR 2 years must passsince the end of thesentence for all othersupervisions (exceptthose listed in 9 , which can never beexpunged). a. For certain offenses listed in the law, at least 5 years have passed since I completed my s upervision successfully ; OR b. At least 2 years ha ve passed since I completed my s upervision successfully. 9 . I am NOT seeking to expunge an y arrest s or charge s that resulted in s upervision for: a. Driving Under the Influence; OR b. Any sexual offense against a person under the age of 18; OR c. Reckless Driving when I was 25 years of age or older. 10 . For at least one case, I received a sentence of s upervision for Reckless Driving; AND a. I was under the age of 25 when the offense was committed; AND b. I have no other convictions for DUI or Reckless Driving; AND c. I have reached the age of 25 . 1 1 . I qualify to have my filing fees and State Police fees waived under the Cook County Fee Waiver Pilot Program: a. I am filing this Request in Cook County prior to January 1, 201; AND b. IF YOU ARE ONLY REQUESTING TO EXPUNGE CASES, DO NOT FILL OUT SECTIONS 13 - 22. See How to Expunge and/or Seal a Criminal Record to make sure your cases can be hidden by sealing your record. For help filling out this table see pages 12 226 15. 1 2 . I am requesting to seal records . Yes No (If no, skip Sections 1 3 - 2 2 ) American LegalNet, Inc. www.FormsWorkFlow.com Enter the Case Number given by the Circuit Clerk: Page 3 of 4 In 1 3 , e nter all eligible arrests, charges, and convictions you want sealed. Enter all charges for each case number. For Outcome, enter an outcome that reflects the outcome of your case. Use the shortened version of the outcome from the Outcome Abbreviations box. 1 3 . I ask the Court to SEAL the following arrests, charges , or convictions from the records of the Arresting Agency, the Circuit Clerk , and the Illinois State Police: Arrest or Case Number Arresting Agency Charge (list all charges for each case number ) Date of Arrest Outcome (for example, MC, FC, or CE ) If you need more room to list additional eligible arrests or charges use the Additional Arrests or Cases for Sealing form and check the box. 14226 16 must be true for you to use this form. Outcome Abbreviations For 14, traffic offenses cannot be sealed unless they were an eligible Class A or B misdemeanor. MC Misdemeanor Conviction FC Felony Conviction CE Certificate of Eligibility for Sealing from PRB QP Qualified Probation Successfully C ompleted I have listed additional arrests or cases on the attached Additional Arrests or Cases for Sealing form. In 17 - 21, check ALL boxes that apply. 1 4 . I am not asking to seal arrests or charges for minor traffic offense s, unless I was released In 1 7 and 1 8 a 226 c , some misdemeanor supervisions and convictions cannot be sealed, like DUI, some Reckless Driving Offenses, Domestic Battery, some Sexual Offenses, and Dog Fighting. In 18b, some Class 3 and Class 4 felony offenses can be sealed, like Theft, Possession of Cannabis, Possession of a Controlled Substance, and a few others. without being charged. 1 5 . I am not asking to seal arrests or charges for felony offense s , unless the felony was reduced to a n eligible misdemeanor, or is otherwise eligible to be sealed. 1 6 . I am not asking to seal a felony conviction that happened after the sealing of a prior felony conviction. 1 7 . At least 2 years have passed since I successfully completed my supervision, for eligible offenses. 1 8 . A t least 3 years have passed since the end of my last sentence (Unless #20 applies) ; AND ( C heck all that apply) : a . I received a misdemeanor conviction for an offense subject to sealing; b . I received a felony conviction for an offense subject to sealing. If it was a drug case, I have attached the results of a drug test that I passed within the last 30 days. c . I successfully complet