,Q WKH ň &,5&8,7 &2857 ʼn For File Stamp Only 2I 6W /RXLV &RXQW\ 0LVVRXUL DIVISION _____________________________________________ Plaintiff CASE NUMBER vs. Defendant(s)/ Agency(ies) to be notified: COURT ORI NUMBER 02- Check & Complete all that apply: Ŋ ŋ CIRCUIT COURT DIVISION ___________________________ ST. LOUIS COUNTY POLICE DEPT. ASSOCIATE COURT DIVISION ___________________________ _____________________________ POLICE DEPT. MUNICIPAL COURT DIVISION ___________________________ MISSOURI HIGHWAY PATROL TROOP_________ CRIMINAL RECORDS REPOSITORY PROSECUTOR’S OFFICE (INCLUDE NAME OF COUNTY OR CITY) OF: OTHER (INCLUDE NAME AND LOCATION OF AGENCY) ST. LOUIS COUNTY PROSECUTOR’S ______________________________________________ CITY/ VILLAGE OF_________________________ PROSECUTOR’S ______________________________________________ 3(7,7,21 )25 (;381*(0(17 2) $55(67 5(&25'6 Pursuant to Section 610.122, RSMo, I request that the court issue an order to expunge my record of arrest, for the criminal case described below: I am filing this petition in the county where the arrest occurred and I hereby swear that I have no prior or subsequent misdemeanor or felony convictions and I did not receive a suspended imposition of sentence (SIS) for the offense for which the arrest was made or for any offense related to the arrest. I also state that the arrest was based on false information, there is no probable cause at the time of the action to expunge to believe that I committed the offense and no charges will be pursued as a result of the arrest, and no civil action is pending relating to the arrest or the records sought to be expunged. Pursuant to Section 610.123, RSMo, I have attached the petitioner’s fingerprints on a standard fingerprint card, and I have reason to believe the agencies named above as defendants may possess records subject to expungement. FULL NAME DATE OF BIRTH SEX SOCIAL SECURITY NUMBER F RACE DRIVER’S LICENSE NUMBER ADDRESS AT TIME OF ARREST DATE OF ARREST M OFFENSE CHARGED ARREST CITATION NUMBER IF CRIMINAL CHARGES WERE FILED, DATE OF DISMISSAL OR REVERSAL COUNTY WHERE PETITIONER WAS ARRESTED (IF ARREST OCCURRED IN NAME OF ARRESTING AGENCY A MUNICIPALITY, ALSO NAME MUNICIPALITY) CASE NUMBER AND DIVISION OF COURT OF THE OFFENSE CIRCUIT ASSOCIATE MUNICIPAL DIVISION__________ #________________________________________________________________ NOT APPLICABLE I, plaintiff, swear the facts stated in the above petition are true according to my best knowledge and belief. Subscribed and sworn to before me this____________ day of ____________________________, _______________. ______________________________________________________ Plaintiff’s Signature is required / Address _________________________________________________________ __________________________________________________ Notary Public/ Judge/ Clerk My Commission expires: __________________ _________________________________________________________ Attorney for Petitioner MBE# __________________________________________________________; ____________________________________________________ Address CCCM70 Rev. 08/03 WHITE - File YELLOW - Agency 1 PINK - Agency 2 GOLDENROD - Petitioner American LegalNet, Inc. www.FormsWorkFlow.com