File No. STATE OF NORTH CAROLINA In The General Court Of Justice District Superior Court Division County STATE VERSUS REQUEST AND REPORTS CONVICTIONS/EXPUNCTIONS DISMISSALS AND DISCHARGE Name And Address Of Defendant (Type Or Print) G.S. 15A-145, 15A-146, 90-96, 90-113.14 Race Sex DOB Social Security No. Offense To Be Expunged Or Dismissed G.S. No. Relief Requested And Statute Under Which Application Made (Check Only One) 15A-145 90-113.14(b) Expunction of records under: 15A-146 90-113.14(d) Dismissal of charges and discharge of defendant under: 90-96(b) 90-113.14(e) 90-96(a) 90-96(d) 90-96(e 90-113.14(a) OFFENSE INFORMATION DATE (Check And Give Date For All Which Apply) Date Offense Committed Date Of Arrest, Indictment Or Service Of Other Initiating Process Date Of Dismissal Or Finding Of Not Guilty Date Of Guilty Plea Or Date Found Guilty Date Of Dismissal And Discharge Under G.S. 90-96(a) or G.S. 90-113.14(a) Date Of Conviction Name And Address Of Arresting Agency Name And Address Of Defendant's Attorney OFFENSE INFORMATION I certify that an application under the statute identified above and all affidavits required under that statute have been filed in this case, that I have served copies on the district attorney, and that the information set forth above is a complete and accurate statement of the information on file in the office of the Clerk of Superior Court. Date Signature Defendant Attorney REQUEST BY JUDGE To The State Bureau Of Investigation, P.O. Box 29500, Raleigh, NC 27626: Please prepare, certify on the reverse side, and attach to this Request any Criminal Record History Information for the petitioner. Then forward this Request with Criminal Record History Information attached, confidentially to: Records Officer, Administrative Office of the Courts, Courier Box 56-10-50, Raleigh, NC, OR if courier is not available, mail to P.O. Box 2448, Raleigh, NC 27602. To The Records Officer, Administrative Office of the Courts: Please complete the report on the reverse side and return it, along with any Criminal Record History Information previously attached to this Request by the SBI, to the Clerk of Superior Court, Attn: Presiding Judge. Date Name Of Presiding Judge (Type Or Print) AOC-CR-237, Rev. 4/01 2001 Administrative Office of the Courts Signature Of Presiding Judge (Over) 2001 © American LegalNet, CRIMINAL RECORD HISTORY INFORMATION To Any Presiding Judge In The Above Named County And Court: (Confidential) I have conducted a search of the criminal records of the North Carolina State Bureau of Investigation and the Federal Bureau of Investigation, based on the information provided by you, which has not been verified by fingerprint comparisons, and certify that there is no criminal record for the defendant identified on the reverse side of this form. the Criminal Record History Information which is attached is a true and accurate statement of all information contained in the criminal records of the State and Federal Bureaus of Investigation for the defendant identified on the reverse side of this form. Date Signature Of S.B.I. Official REPORT BY ADMINISTRATIVE OFFICE OF THE COURTS To Any Presiding Judge In The Above Named County And Court: (Confidential) I have searched the confidential file which contains the names of all persons granted an expunction or dismissal and discharge in North Carolina and certify that there is no record under the name of the defendant of any expunction or dismissal and discharge under any statute of there is a record under the name of the defendant identified on the reverse side of this form as follows: Date Signature Of Records Officer CERTIFICATION BY CLERK To The Arresting Agency Identified On The Reverse And To The Records Officer, Administrative Office Of The Courts, Courier Box 56-10-50, Raleigh, NC, OR if courier is not available, mail to P. O. Box 2448, Raleigh, NC 27602: I certify that this form and the attached Order are true and complete copies of the originals in this case and are being forwarded for compliance with any applicable provisions of the Order. Date Signature Name (Type Or Print) INSTRUCTIONS: Clerk Of Superior Court Assistant CSC Upon the completion of an application/motion to expunge, or dismiss and discharge, which is a separate document prepared by the defendant or his attorney, the procedures for this form are as follows: 1. No order should be entered until this form has been completed by the defendant, a judge, S.B.I. and AOC and has been referenced to the Clerk as explained below. 2. The defendant or attorney should complete all "Offense Information" on the reverse side of this form from the court file, sign the certificate, obtain the judge's signature and send to the S.B.I. 3. The S.B.I. shall then complete CRHI and send to the AOC. 4. The AOC shall complete the report and mail to the Clerk of Superior Court in the county where the expunction is pending in an enveloped marked "Attn: Presiding Judge-Confidential-AOC-CR-237 Enclosed-File No.-Defendant's Name." 5. The Clerk places the sealed envelope in the file to be opened by the presiding judge when the application is heard. 6. It is the responsibility of the petitioner to determine if the AOC-CR-237 has been returned and then to ask the Clerk or D.A. to schedule an application/motion to expunge for hearing. 7. If order granting dismissal and discharge is entered, the Clerk notifies the AOC. 8. If Order of Expunction is entered, the Clerk makes two copies of this form, completes "Certification By Clerk" on each copy, attaches a copy of the Order to each copy, and sends one set of each to arresting agency and the AOC. The Clerk retains the original to be disposed of with the papers in this case. No other copy is made or kept. 9. If application is denied, all copies of the AOC-CR-237 and any accompanying information from the S.B.I. or AOC shall be destroyed, unless the court orders otherwise. AOC-CR-237, Side Two, Rev. 4/01 2001 Administrative Office of the Courts 2001 © American LegalNet,