NHJB-2981-D (01/01/2019) Page 1 of 3 THE STATE OF NEW HAMPSHIRE JUDICIAL BRANCH htt p ://www.courts.state.nh.us Court Name: Case Name: Case Number: (if known) Charge ID: JUVENILE PETITION TO ANNUL RECORD (NO FEE) APPLICANT222S INFORMATION Full Name: Date of Birth: Address: City/Town State Zip Code Telephone Number: E-mail Address: (optional) CHARGE INFORMATION For the charge that you are seeking to annul, list the RSA (statute) violated, name of crime/offense, date of offense, date of conviction or other disposition, date all terms and conditions of the sentence were completed, and disposition (sentence) imposed by the Court: RSA Violated Name of Crime/Offense Date of Offense Date of Conviction or Other Disposition Date Sentence Completed Description of Sentence or other Disposition: American LegalNet, Inc. www.FormsWorkFlow.com Case Name: Case Number: JUVENILE PETITION TO ANNUL RECORD NHJB-2981-D (01/01/2019) Page 2 of 3 In accordance with 651:5 and RSA 260:3, the applicant requests that the Court annul the record of arrest and charge, and if applicable, conviction and sentence in the following matter: PLEASE COMPLETE A SEPARATE FORM FOR EACH OFFENSE APPLICANT222S CERTIFICATION The applicant was convicted of the above crime/offense, and seeks annulment of any record of arrest, the offense/charge, conviction and sentence, and the applicant represents to the Court that: 1. The conviction occurred between May 14, 2014 and July 1, 2015 while the applicant was 17 years of age. 2. All the terms and conditions of the sentence listed above have been completed, including the payment of any fine, restitution or other cost, any probation period and any suspended sentence imposed by the Court. I swear or affirm, under penalties of law, that the above facts are true and correct to the best of my knowledge. Date Applicant222s Signature Name of Counsel Counsel222s Signature Address American LegalNet, Inc. www.FormsWorkFlow.com Case Name: Case Number: JUVENILE PETITION TO ANNUL RECORD NHJB-2981-D (01/01/2019) Page 3 of 3 FOR COURT USE ONLY: IT IS ORDERED AND CERTIFIED: CERTIFICATE OF ANNULMENT That the record of conviction and sentence in the above entitled case, together with any record of arrest or charge therein, is hereby annulled. The applicant has shown that issuance of this order is warranted under the statute. The Court DENIES the applicant222s petition pursuant to RSA 260:3 because the Court finds, based on clear and convincing evidence, that the subject offense would have qualified for transfer to the superior court pursuant to RSA 169-B:24 and that the prosecution would have pursued such transfer. The offense is one which would be prosecuted as an adult criminal offense after July 1, 2015 against persons who have not yet reached 18 years of age. Date Signature of Judge Printed Name of Judge CC: Prosecutor Defendant Defense Attorney Dept. of Safety 226 Criminal Records DMV Dept. of Corrections Police Department Other Attorney General District Division # Sentence Review American LegalNet, Inc. www.FormsWorkFlow.com