EXP102 State ENG Rev 01/15 www.mncourts.gov/forms Page 1 of 4 State of Minnesota District Court County of Judicial District: Court File Number: Case Type: Criminal State of Minnesota, Plaintiff Notice of Hearing and vs. Petition for Expungement (Sealed Records) Defendant Minn. Stat. 247 609A.03 Or Inherent Authority Notice of Hearing Notice To Law Enforcement/Government Agency/Prosecutor: Any objection to expungement in this case shall be filed with the court as soon as possible, and within 60 days. This matter is scheduled for hearing on (date) at (time); at (location). Petition for Expungement 1. I state under penalty of perjury that I am petitioning the court for expungement (sealing) of a criminal record. 2. My full name, and all other legal names or aliases I have been known as, are: 3. My date of birth is: 4. The following are all of the addresses I have lived at since the date of the offense for which I am seeking expungement: (street address, city, state) American LegalNet, Inc. www.FormsWorkFlow.com EXP102 State ENG Rev 01/15 www.mncourts.gov/forms Page 2 of 4 5. I am seeking expungement because (Include whether expungement is sought for employment, housing, or licensure purposes, the statutory or other legal authority under which expungement is sought, and state in detail and with specifics why expungement should be granted. Attach additional pages if necessary.): 6. My criminal record including all charges, convictions, stays of adjudication or imposition of sentence and pending actions for misdemeanors, gross misdemeanors or felonies in this state, another state, federal court, or a foreign country, whether the conviction occurred before or after the offense for which expungement is sought, consists of: Case# County-State Type of Charge Date of Offense Conviction (Y/N) Date (If Yes) 7. I have no criminal records, other than listed at #6, in this state or elsewhere. 8. All prior requests for expungement, pardon or sealing of a criminal record, whether for this offense or for any other offense, whether granted or not, that I have made include: 9. I qualify for an expungement because: A criminal case against me for a controlled substance violation has been dismissed and the proceedings have been discharged (use Order Concerning Sealing/Expunging of Record - Minn. Stat. 247 609A.02, subd. 1 or 2 (court form EXP106)); I was certified or referenced for prosecution as an adult for a crime I committed when I was a juvenile (use Order Concerning Sealing/Expunging of Record - Minn. Stat. 247 609A.02, subd. 1 or 2 (court form EXP106)); American LegalNet, Inc. www.FormsWorkFlow.com EXP102 State ENG Rev 01/15 www.mncourts.gov/forms Page 3 of 4 A criminal matter was resolved in my favor (use Order Concerning Sealing/Expunging of Records - Minn. Stat. 247 609A.02, subd. 3 (court form EXP105)); I successfully completed the terms of a diversion program or stay of adjudication and have not been charged with a new crime for at least one year since completion of the diversion program or stay of adjudication (use Order Concerning Sealing/Expunging of Records - Minn. Stat. 247 609A.02, subd. 3 (court form EXP105)); I was convicted of or received a stayed sentence for a petty misdemeanor or misdemeanor and have not been convicted of a new crime for at least two years since discharge of the sentence for the crime (use Order Concerning Sealing/Expunging of Records - Minn. Stat. 247 609A.02, subd. 3 (court form EXP105)); I was convicted of or received a stayed sentence for a gross misdemeanor and have not been convicted of a new crime for at least four years since discharge of the sentence for the crime (use Order Concerning Sealing/Expunging of Records - Minn. Stat. 247 609A.02, subd. 3 (court form EXP105)); I was convicted of or received a stayed sentence for a felony violation of an offense listed in Minn. Stat. 247 609A.02, subd. 3(b), and have not been convicted of a new crime for at least five years since discharge of the sentence for the crime (use Order Concerning Sealing/Expunging of Records - Minn. Stat. 247 609A.02, subd. 3 (court form EXP105)); or I was convicted of an offense that does not qualify for expungement under Minn. Stat. 247 609A.02, subd. 3, but I have rehabilitated myself. The benefit to me outweighs the disadvantage to the public and the burden on the court (use Findings of Fact, Conclusions of Law and Order to Seal/Expunge Judicial Records Only (court form EXP107)). 10. The details of the offense I want to expunge are: Case #Jurisdiction/City where the offense occurred: Type of Offense: Date of Offense: This was a conviction or a dismissal. Date of conviction or dismissal: Date of discharge from probation/completion of diversion or stay: 11. The names of the victims in this case are: Or, there were no identifiable victims. 12. There is is not a current or prior order for protection, restraining order or other no-contact order prohibiting me from contacting the victims (include copies of any orders to petition). American LegalNet, Inc. www.FormsWorkFlow.com EXP102 State ENG Rev 01/15 www.mncourts.gov/forms Page 4 of 4 13. Since conviction of this offense, I have taken the following steps toward personal rehabilitation, including treatment, work, community involvement, or other personal history (Attach additional pages if necessary.): Or, there was no conviction for this offense. 14. I request that the court seal any private or confidential data submitted by the responding agencies or jurisdictions (Minn. Stat. 247 609A.03, subd. 3(d)). 15. I request that if expungement is ordered, each agency and jurisdiction that receives the order must send a letter to me at the address provided confirming receipt of the expungement order and that the record has been expunged (Minn. Stat. 247 609A.03, subd. 8(b)). 16. Please explain any mitigating or aggravating factors relating to the underlying crime, including your level of participation, the context and circumstances of the underlying crime and what risk, if any, you pose to individuals or society. "I declare under penalty of perjury that everything I have stated in this document is true and correct." Minn. Stat. 247 358.116. County and State where signed Dated: Signature Name: Address: City/State: Zip Code: Telephone: American LegalNet, Inc. www.FormsWorkFlow.com