Approved, SCAO Original - Court 1st copy - State Police 2nd copy - Arresting Agency 3rd copy - Prosecuting official 4th copy - Defendant 5th copy - Attorney General STATE OF MICHIGAN JUDICIAL CIRCUIT JUDICIAL DISTRICT ORI MICourt address ORDER ON APPLICATION TO SET ASIDE CONVICTION CASE NO. Court telephone no. Defendant's name, address, and telephone no. Police Report No. THE PEOPLE OF The State of Michigan v CTN/TCN Date of Offense SID Charge DOB Instructions: An order may not be entered until receipt of the report of the Michigan State Police. Copies of the order must be sent to the Michigan State Police and the prosecuting official. See other side for a list of offenses in MCL 780.621(3) that may not be set aside. This order should not be used with applications to set aside a conviction under MCL 780.621(4), involving victims of human trafficking. 1. An application to set aside THE COURT FINDS: Conviction was filed on Date . 2. The Michigan State Police has reported the required information from its records to the court. 3. The applicant has not been convicted of more than one felony and two misdemeanors as defined in MCL 780.621. 4. The conviction is not for an offense listed in MCL 780.621(3) as a conviction that may not be set aside. 5. It has been at least five years since the sentence was imposed or since the defendant was discharged from imprisonment, probation, or parole for the conviction, whichever is later. 6. An opportunity has been given to the Attorney General and prosecuting official to contest the application. 7. Circumstances and behavior of the applicant justify setting aside the conviction, and it is consistent with the public welfare. IT IS ORDERED: (If any item from 2 through 7 is not checked, then item 8 must be checked.) 8. The application is denied. Applicant may file another application to have this conviction set aside three years after the date of this order. OR earlier than three years after the date of this order, but no sooner than Date . 9. The conviction listed in item 1 in this case is set aside. Under MCL 780.623 the court clerk, the arresting agency, and the Michigan State Police shall maintain a nonpublic record of the order setting aside conviction and of the arrest, fingerprints, conviction, and sentence in this case. If the conviction is for a nontraffic offense that was reportable to the Secretary of State in accordance with MCL 257.732(22), the driving record shall not be expunged. Date Judge Bar no. NOTE TO APPLICANT: Under MCL 780.622, if this order sets aside a conviction for a listed offense as defined in MCL 28.722 of the Sex Offenders Registration Act, you are still considered to have been convicted of that offense and you must comply with the registration and reporting requirements of the act. Under MCL 769.16a the clerk of the court shall advise the Michigan State Police Criminal Justice Information Center of the disposition. MC 228 (10/15) ORDER ON APPLICATION TO SET ASIDE CONVICTION MCL 780.621, MCL 780.623 American LegalNet, Inc. www.FormsWorkFlow.com Convictions that May Not Be Set Aside: MCL 780.621(3) prohibits the court from setting aside certain convictions as follows: (a) (b) (c) (d) (e) (f) A felony for which the maximum punishment is life imprisonment or an attempt to commit a felony for which the maximum punishment is life imprisonment. A violation or attempted violation of section 136b(3), 136d(1)(b) or (c), 145c, 145d, 520c, 520d, or 520g of the Michigan penal code, 1931 PA 328, MCL 750.136b, 750.136d, 750.145c, 750.145d, 750.520c, 750.520d, and 750.520g. A violation or attempted violation of section 520e of the Michigan penal code, 1931 PA 328, MCL 750.520e, if the conviction occurred after the effective date of the amendatory act that added this subdivision. A traffic offense, including, but not limited to, a conviction for operating while intoxicated. A felony conviction for domestic violence, if the person has a previous misdemeanor conviction for domestic violence. A violation of chapter LXVIIA or chapter LXXXIII-A of the Michigan penal code, 1938 PA 321, MCL 750.462a to 750.462j and 750.543a to 750.543z. American LegalNet, Inc. www.FormsWorkFlow.com