PETITION TO SEALTo: Commissioner of Probation, One Ashburton Place, Rm. 405, Boston, MA 02108SELECT appropriate box(es). If 1, 2, or 3 are selected, you must sign the corresponding numbered affidavit below.PART A 1 - 4Section 100B - Chapter 276. Delinquency (juvenile) cases, all sentence elements of which, and of any subsequent court appearances, were completed 3 years prior to this request.Section 100A - Chapter 276. Misdemeanor cases, all sentence elements of which, and any subsequent court appearances, were completed 5 years prior to this request (or, which was a felony when committed, and is presently a misdemeanor). Section 100A - Chapter 276. Felony cases, all sentence elements of which, and of any subsequent court appearances, were completed 10 years prior to this request. For eligible sex offenses 15 years prior to this request.Section 100A - Chapter 276. Recorded offense which is no longer a crime, except where the elements of the offense continue to be a crime under a different designation.2314In accord with the provision of Chapter 276, Sections 100A and 100B, as established by Chapter 686 of the Acts of 1971, Chapter 404 of the Acts of 1972 , Chapter 322 of the Acts of 1973 and Chapter 256 of the Acts of 2010, respectively, I hereby request that my record of adult criminal and/or juvenile Massachusetts court appearances and dispositions be sealed forthwith. Print Date of Birth: Alias/Maiden/Previous nameLast nameMiddle nameFirst name Mailing Address City State Zip Occupation Social Security # Place of Birth Father's Name Mother's Maiden Name Husband/ Wife's Name Petitioner's Signaturea) My delinquency court appearances or dispositions including court supervision, probation, commitment or parole, the records for which are to be sealed, terminated not less than three years prior to said request; b) I have not been adjudicated delinquent or found guilty of any criminal offense within the commonwealth in the three years preceeding such request, except motor vehicle offenses in which the penalty does not exceed a fine of fifty dollars nor been imprisoned under sentence or committed as a delinquent within the commonwealth within the preceeding three years; and c) I have not been adjudicated delinquent or found guilty of any criminal offenses in any other state, United States possession or in a court of federal jurisdiction, except such motor vehicle offenses as aforesaid, and have not been imprisoned under sentence or committed as a delinquent in any other state or county within the preceeding three years.1.2.3.Signed under penalties of perjury,To the best of my knowledge:To the best of my knowledge: Signature of Petitionera)All of my court appearance and court disposition records, including any period of incarceration or custody for any misdemeanor occurred not less than five years prior to this request; b) that my court appearance and court disposition records, including any period of incarceration or custodyfor any felony occurred not less than ten years prior to this request; c) that I have not been found guilty of any criminal offense within the commonwealth in the case of a misdemeanor, five years before such request, and in the case of a felony, ten years before such request, except motor vehicle offenses in which the penalty does not exceed a fine of fifty dollars; d) I have not been convicted of any criminal offense in any other state, United States possession or in a court of federal jurisdiction, except such motor vehicle offenses as aforesaid, and have not been imprisoned in any other state or county in the case of a misdemeanor within the preceeding five years and in the case of a felony the preceeding ten years; and e) my record does not include convictions of offenses other than those to which the section applies, or convictions for violations of sections 121 to 131 H, inclusive, of chapter 140 or for violations of chapter 268 or chapter 268 A.Signed under penalties of perjury, Signature of Petitioner Petition Allowed/Disallowed01020304Allowed (Copy to Clerk and Probation Office)Reason for Disallowance (Copy to petitioner only)(OCP 4/12)PETITIONER NOT TO WRITE BELOW THIS LINE American LegalNet, Inc. www.FormsWorkFlow.com