� � The State of Michigan THE PEOPLE OF � � 1. � On en-USDateen-US I was convicted of en-USOffenseen-US . en-USA certified copy of the conviction is attached. 2. � I en-USrequesten-US that the court issue an order to set aside the above conviction as provided by law. I consent to use of the nonpublic � record created by MCL 780.623 to the extent authorized by MCL 780.623. 3. � � No other application has been filed to set aside this conviction. en-USOR � � An application was previously filed to set aside this conviction on en-USDateen-US . The application was disposed � � of as follows: en-US en-US . � 4. � � No other application has been filed to set aside another conviction. en-USOR � � An application was previously filed in � � this court � � the en-US en-US Court to set aside a � conviction for en-US en-US , in addition to the conviction in item 1. The application was disposed � of as follows: en-US en-US . 5. � At least five years have passed since sentence was imposed or discharge from imprisonment, probation, or parole for this � � conviction, whichever is later. 6. � � I have not had any convictions deferred and dismissed. � � I have had the following conviction(s) deferred and dismissed: � � en-US en-US . 7. � � There are no other criminal charges pending against me. � � There are criminal charges pending against me in the � en-US en-US Court, case number en-US en-US . 8. � I have not been convicted of more than one felony and two misdemeanors as defined in MCL 780.621. � en-USApplicant Signature � � en-USSubscribed and sworn to before me on en-USDateen-US , en-US en-US County, Michigan.en-USMy commission expires: en-USDateen-US Signature: en-USDeputy clerk/Notary publicen-USNotary public, State of Michigan, County of en-US American LegalNet, Inc. www.FormsWorkFlow.com Case No. en-USTO: Michigan Attorney General and en-USProsecuting officialen-USA hearing will be held on the above application to set aside conviction on en-USDateen-US at en-USTimeen-USat en-USLocationen-US before Judge � Bar no. en-US .en-USI certify that copies of this application, certified record of conviction, and notice of hearing were served on theen-US � prosecuting official on en-USDateen-US by first-class mail addressed to the last-known address.en-US � Attorney General on en-USDateen-US by first-class mail addressed to the last-known address.en-USI certify that copies of this application, certified record of conviction, and the fingerprint card, accompanied by the required fee, wereen-USserved on the Michigan State Police on en-USDateen-US by first-class mail addressed to the last-known address. en-USDate � en-USApplicant/Attorney signatureen-USINSTRUCTIONS:en-USFor additional instructions and an online interview that will help you create forms, go to michiganlegalhelp.org. 1. � Determine whether you are eligible to apply to have your conviction set aside according to MCL 780.621. You must complete � a separate application for each conviction if you are applying to have more than one conviction set aside. 2. � Find out the exact date of conviction and the charge from the court. Get a certified copy of the adjudication and attach it to � your application. 3. � Swear to the truth of the statements in this application and then sign it in the presence of the court clerk or a notary public. 4. � Make four copies of all attachments and this application. Take all copies to the court clerk. 5. � Depending on local practice, the clerk of the court may set a hearing date at the time of filing. If a hearing date is set at the � time of filing, the clerk of the court will complete the Notice of Hearing. 6. � Go to the local law enforcement agency for a fingerprint card and get fingerprinted on the applicant card (RI-8). There may � be a fee for fingerprinting. Fill out the card completely. 7. � Make out a money order or check to the State of Michigan for the application. The application fee is $50.00. This fee is sent � with the application packet to the Michigan State Police for processing. 8. � Mail a copy of the application packet, application fee, and the fingerprint card to the Michigan State Police by first-class mail � to Michigan State Police, Criminal Justice Information Center - Criminal History, PO Box 30266, Lansing, Michigan 48909. 9. � Mail a copy of the application packet to the Attorney General of the State of Michigan by first-class mail to Office of the � � Attorney General, Criminal Appellate Division, PO Box 30217, Lansing, Michigan 48909. 10. � Mail a copy of the application packet to the correct prosecuting official where the conviction occurred (county, city, or � � township) by first-class mail. See www.michiganprosecutor.org/about-us-menu/prosecutor-directory for the addresses of � county prosecutors. 11. � On both copies of the application, fill in the Proof of Service on the back of the form. After you fill out and sign the Proof of Service, � mail or take one of the remaining application packets with the completed Proof of Service to the court. Keep the other copy � of the application packet for your records. en-USNOTICE OF HEARING en-USPROOF OF SERVICE en-USThe hearing cannot be held until the court receives the en-USMichigan State Police report required by MCL 780.621(9). American LegalNet, Inc. www.FormsWorkFlow.com