Motor Vehicle Administration 6601 Ritchie Highway, N.E. Glen Burnie, Maryland 21062 AJ-058 (03-10) Expungement Request Driver’s License Number Date of Birth Name - First Street Address Middle City Last State Zip Code I certify that I ❒ have ❒ have not been convicted for a criminal offense in which a motor vehicle was involved. If you have been convicted of such an offense please furnish the following: Location of Offense Date of Offense I certify that I ❒ have ❒ do not have any traffic summonses or criminal charges involving a motor vehicle now pending or outstanding, in Maryland or in any other state. If you have any such summonses or charges pending or outstanding, please complete the following: Nature of Pending Offenses Trial Date(s) I certify that the statements made above are true and correct to the best of my knowledge, information and belief. Signature Date Note: You will be advised by mail within four weeks of the outcome of your request. Do not send a check or money order with this request. If a driving record is needed you may obtain a certified/ non-certified copy at the Motor Vehicle Administration. Send this completed form to: Motor Vehicle Administration, Administrative Adjudication Division, Room 211 6601 Ritchie Highway N.E., Glen Burnie, MD 21062. American LegalNet, Inc. www.FormsWorkFlow.com For more information, please call: 1-800-950-1MVA (1682) (to speak with a customer service representative), From Out-of-State: 1-301-729-4550, TTY for the hearing impaired: 1-800-492-4575. Visit our website at: www.MVA.Maryland.gov