INSTRUCTIONS FOR COMPLETION OF EXPUNGEMENT FORM Note: For your convenience, this form may be printed. However, it must be completed in its entirety and be personally presented to the Court as outlined below. 1. Complete all blanks with information relative to your case. If you do not have this information, you may come to the Clerk of Courts Office, Suite 1005, Washington County Courthouse to review your file. If your case was disposed of at the district justice level, you must contact the district justice for pertinent information. 2. If your case was disposed of by ARD or PWOV, the ARD Completion Form (Exhibit “A”) must be completed by the Adult Probation Office. Please see packet for directions and requirements of the Adult Probation Office. If your case was disposed of at the District Justice level, the Court and the District Attorney require that a copy of the district justice docket be attached to your petition. 3. If your case was disposed of by a Judge of the Court of Common Pleas and you were ordered to pay costs, Exhibit “B” (the statement that all costs and fines are paid in full) must be completed by the Clerk of Courts Office. 4. Once the form is completed in its entirety, a copy of the entire Petition (including Exhibits “A” and “B”, if applicable) must be served on the District Attorney. The District Attorney will complete the District Attorney’s Statement form included in this packet. You must then take the form to the sentencing judge. You should check with the Judge who disposed of the case to determine when Motions court is held in order that you may appear in person to present the petition to the court for action. 5. When the judge signs the Court Order permitting expungement, you must pick it up from the judge and bring it to the Clerk of Courts Office, along with a filing fee of $55.50. The Clerk of Courts office will then supply you with certified copies of the Order. You will be responsible for either mailing or personally serving these copies to the appropriate agencies listed in the Court Order. 6. Immediately upon filing, your case will be expunged by the Clerk of Courts. The various other agencies require additional time to complete this request. 7. For your convenience, a list of the Washington County District Justices and police departments is also available at the Clerk of Courts Office. The same information is also available in your telephone directory. BARBARA GIBBS, Clerk of Courts American LegalNet, Inc. www.FormsWorkflow.com IN THE COURT OF COMMON PLEAS OF WASHINGTON COUNTY, PENNSYLVANIA CRIMINAL DIVISION COMMONWEALTH OF PENNSYLVANIA VS. ) ) ) No. _____________________________ ) Common Pleas Docket Number and ) OTN Number or District Justice Number PETITION FOR DISMISSAL OF CHARGES AND EXPUNGEMENT AND NOW, this _________ day of ________________, 20 _____, comes the defendant, and respectfully requests that this Petition for Dismissal of Charges and Expungement be granted, for the following reasons: 1. On _____________________, 20 _____, the defendant was: (check one of the following) _______ A. Placed in the Accelerated Rehabilitative Disposition Program by Judge . _______ B. Charges were dismissed or a nol. pros. was entered by Judge . _______ C. Charges were disposed of as follows by District Justice : . 2. The defendant has satisfactorily completed the Program prescribed and complied with the conditions as verified by the Adult Probation Office labeled “Exhibit A” and attached hereto, if applicable. 3. In accordance with Pennsylvania Rules of Criminal Procedure 185, the Affidavit of the Clerk of Courts certifying compliance with all of the terms and conditions related to the payment of costs, fines, and/or restitution imposed by the aforementioned Order of Court, is labeled “Exhibit B” and attached hereto, if applicable. 4. A copy of this Petition was served upon the District Attorney of Washington County, Pennsylvania, and an Affidavit of Service to that effect appears on Page 2 of this Petition. WHEREFORE, in accordance with the Pennsylvania Rules of Criminal Procedure, Rules 185 and 186, this defendant moves the Honorable Court to dismiss the charges set forth in the above-captioned proceeding and Order the Expungement of the Arrest Record and all other documents pertaining to the defendant in the abovecaptioned proceeding. Respectfully submitted, Defendant EXPUNGEMENT PETITION – PAGE 1 OF 2 American LegalNet, Inc. www.FormsWorkflow.com VERIFICATION I verify that the statements made in the foregoing document are true and correct to the best of my knowledge, information, and belief. I understand that false statements herein are made subject to penalties of 18 Pa. C.S.A. §4904, relating to unsworn falsification to authorities. Defendant AFFIDAVIT OF SERVICE I, , hereby certify that I served upon the Commonwealth of Pennsylvania, through the Office of the District Attorney of Washington County, Pennsylvania, a copy of the Petition for Expungement of Arrest Record in the above-captioned matter, by leaving a copy with the secretary in charge of the Office of the District Attorney of Washington County, Pennsylvania at the Washington County Courthouse, Washington, PA 15301, on the _________ day of ____________________, 20 ______. DATE DEFENDANT EXPUNGEMENT PETITION – PAGE 2 OF 2 American LegalNet, Inc. www.FormsWorkflow.com IN THE COURT OF COMMON PLEAS OF WASHINGTON COUNTY, PENNSYLVANIA CRIMINAL DIVISION COMMONWEALTH OF PENNSYLVANIA VS. ) ) ) No. ) ) CERTIFICATE OF COMPLETION OF ARD I hereby certify that the above-named defendant has successfully completed all of the terms and conditions of his supervision program at this number and term as of the ________ day of _____________________, ____________. ADULT PROBATION OFFICE WASHINGTON COUNTY, PENNSYLVANIA BY: Adult Probation Officer SWORN TO AND SUBSCRIBED BEFORE ME THIS _________ DAY OF _______________, 20 ______. NOTARY PUBLIC My Commission expires: “EXHIBIT A” EXPUNGEMENT PETITION American LegalNet, Inc. www.FormsWorkflow.com IN THE COURT OF COMMON PLEAS OF WASHINGTON COUNTY, PENNSYLVANIA CRIMINAL DIVISION COMMONWEALTH OF PENNSYLVANIA VS. ) ) ) No. ) ) AFFIDAVIT AND NOW, this _______ day of __________________, 20 _____, I hereby certify that the above-named defendant has complied with the terms and conditions imposed by the Court in the above matter relative to payment of all costs of prosecution, including fines and restitution, if Ordered, through the Office of the Clerk of Courts. BARBARA GIBBS Clerk of Courts Washington County, Pennsylvania (Seal) “EXHIBIT B” EXPUNGEMENT PETITION American LegalNet, Inc. www.FormsWorkflow.com IN THE COURT OF COMMON PLEAS OF WASHINGTON COUNTY, PENNSYLVANIA CRIMINAL DIVISION COMMONWEALTH OF PENNSYLVANIA VS. ) ) ) No. ) ) EXPUNGEMENT ORDER OF COURT AND NOW, this ________ day of _________________, 20 _____, a Petition for Expungement having been presented on behalf of the above-captioned defendant and after consideration thereof, IT IS HEREBY ORDERED, ADJUDGED, and DECREED that the Petition be and is hereby GRANTED and that all criminal charges in this matter are dismissed and that the keepers of criminal records named below shall expunge and destroy the official and unofficial arrest and other documents pertaining to the arrest or prosecution or both of the above-named defendant in this criminal proceeding and that each shall request the return of such records which its agency made available to State or Federal agencies and immediately upon receipt thereof shall destroy such records, with the exception of District Attorney’s records concerning ARD, which shall be used solely for the purpose of determining subsequent eligibility for ARD, and that said keepers of such criminal records shall file with this Court an Affidavit stating that the mandates of this Order have been fulfilled. IT IS FURTHER ORDERED, ADJUDGED, and DECREED that the Clerk of Courts shall expunge the Indices of the official and unofficial arrest and other documents pertaining to the arrest or prosecution or both of the above-named defendant in the above-captioned criminal proceedings, and shall seal and impound the aforesaid Affidavits together with the Information, the Complaint, and the original and all copies of this Order, and no person or agency shall be permitted to examine such documents. The Clerk of Courts may advise the defendant or the defendant’s counsel or both of the receipt of said Affidavits. Pursuant to the requirements of Pa.R. 9017 and Section 9122 of the Criminal History Record Information Act, the expungement information concerning this criminal matter is as follows: DEFENDANT’S NAME: DEFENDANT’S DATE OF BIRTH: DEFENDANT’S SOCIAL SECURITY NO.: COURT OF COMMON PLEAS DOCKET NO.: OTN NO.: DJ DOCKET NO.: DATE OF ARREST: ARRESTING AGENCY: EXPUNGEMENT ORDER – PAGE 1 OF 2 American LegalNet, Inc. www.FormsWorkflow.com REASON FOR EXPUNGEMENT: Successful completion of ARD or SPECIFIC CHARGES TO BE EXPUNGED: LIST OF CRIMINAL JUSTICE AGENCIES UPON WHICH CERTIFIED COPIES OF THIS ORDER SHALL BE SERVED BY THE DEFENDANT OR HIS/HER COUNSEL: 1. District Attorney: 2. District Justice: *3. Court Reporter: 4. Arresting Officer and Agency: 5. Pennsylvania State Police Central Repository – 1800 Elmerton Ave., Harrisburg, PA 17110 * 6. 7. Adult Probation Office of Washington Co.: Clerk of Courts of Washington County: * 8. Prothonotary of Washington County – Civil No.: * 9. TRW Credit Bureau, 520 E. Main St., Carnegie, PA 15100 or PO Box 596, Pittsburgh, PA 15230 *10. Department of Transportation, Bureau of Drivers Licensing, P.O. Box 68693, Harrisburg, PA 17106-8693 * IF APPLICABLE BY THE COURT: , J. AFFIDAVIT OF EXPUNGEMENT This is to certify that the official arrest and criminal records and other documents filed pertaining to the particular arrest or prosecution or both of the above-named defendant in the above-captioned criminal proceeding, which are in custody of and in control of this office have been expunged and destroyed. DATE CERTIFYING OFFICER ALL AFFIDAVITS ARE TO BE RETURNED TO THE CLERK OF COURTS OFFICE UNLESS OTHERWISE SPECIFIED. EXPUNGEMENT ORDER – PAGE 2 OF 2 American LegalNet, Inc. www.FormsWorkflow.com IN THE COURT OF COMMON PLEAS OF WASHINGTON COUNTY, PENNSYLVANIA CRIMINAL DIVISION COMMONWEALTH OF PENNSYLVANIA VS. ) ) ) No. ) ) DISTRICT ATTORNEY’S STATEMENT In accordance with Rules 185 and 186 of the Pennsylvania Rules of Criminal Procedure dealing with ARD dispositions, with regard to the Dismissal/Expungement of charges in the above-entitled matter, the Commonwealth, by and through the Office of the District Attorney, hereby: DOES NOT OBJECT OBJECTS, AND REQUESTS A HEARING REQUIRES FURTHER INFORMATION DATE ATTORNEY FOR THE COMMONWEALTH American LegalNet, Inc. www.FormsWorkflow.com