NHJB-2317-DS (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: PETITION TO ANNUL RECORD: Offenses Resolved Prior to 01/01/2019 In accordance with RSA 651:5, 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 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/Statute: Charge: Charge Date: 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: PETITION TO ANNUL RECORD NHJB-2317-DS (01/01/2019) Page 2 of 3 APPLICANT222S CERTIFICATION (Select all checkbox that applies) The applicant was not convicted of the above crime/offense, and seeks only annulment of any record of arrest and/or charge. 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: All the terms and conditions of the sentence listed above have been completed, including the payment of any fine, restitution or other cost, any period of good behavior, any probation period and any suspended sentence imposed by the Court. The time requirements for an annulment under RSA 651:5, III have been met for the crime for which the applicant has been convicted. Since completing the terms and conditions of the sentence imposed by the Court in these matters, the applicant has not thereafter been convicted of any other crime, except a motor vehicle offense classified as a violation, not including driving while intoxicated under RSA 265-A:2, I, RSA 265:82 or RSA 265-82-a. There are currently no charges pending against the applicant in any other Court, except: None of the charges sought to be annulled involve a violent crime, a felony crime of obstruction of justice, or an offense for which an extended term of imprisonment under RSA 651:6 was imposed. The charge sought to be annulled does not have an enhanced penalty for a second conviction. The time requirements for all offenses of which I have been convicted have been met. After considering the investigation and report prepared by the Department of Corrections and any response filed by the State, the Court may make a decision on your Petition to Annul Record without a hearing. If you are requesting a hearing before a judge, please check the box. 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 Address American LegalNet, Inc. www.FormsWorkFlow.com Case Name: Case Number: PETITION TO ANNUL RECORD NHJB-2317-DS (01/01/2019) Page 3 of 3 FOR COURT USE ONLY: ON THE PETITION TO ANNUL RECORD OF ARREST OR CONVICTION AND SENTENCE The Court having found that notice of the forgoing petition was given in accordance with law, and having reviewed the investigative report of the Department of Corrections made in accordance with statute, finds that annulment of the applicant222s record will assist in the applicant222s rehabilitation and will be consistent with the public welfare and the requirements of law, IT IS THEREFORE ORDERED AND CERTIFIED: CERTIFICATE OF ANNULMENT That the record of arrest is hereby annulled. The applicant has shown that issuance of this order is warranted under the statute. That the record of the charge and disposition of dismissal, acquittal or nolle prosequi in the above referenced matter, 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. 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 for the following reason(s): 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