Commonwealth of Pennsylvania v. In the Court of Common Pleas County of Judicial District CRIMINAL DIVISION Docket No ORDER AND NOW, this day of , after consideration of the Petition for Limited Access pursuant to Pa.R.Crim.P. 791 and 18 Pa.C.S. § 9122.1 presented by it is ORDERED that the petition is The defendant's criminal history record information that is subject to limited access shall not be disseminated to an individual, a noncriminal justice agency or an internet website and that dissemination of the defendant's criminal history be limited only to criminal justice agency or government agency as provided in 18 Pa.C.S. § 9122.1. This case qualifies for a limited access order and none of the exceptions under 18 Pa.C.S. § 9122(b) are applicable. The information required under Pa.R.Crim.P. 791 appears on the attached page(s) which is hereby incorporated into this ORDER by reference. BY THE COURT: _____________________ American LegalNet, Inc. www.FormsWorkFlow.com 1. Petitioner's Name: 2. Alias(es): 3. Petitioner's Address: 4. Petitioner's Date of Birth: 5. Petitioner's Social Security Number: 6. Name and address of the Court of Common Pleas, Magisterial District or Philadelphia Municipal Court Judge who accepted the guilty plea or heard the case: 7. Name and address of the affiant as shown on the complaint, if available: 8. Magisterial District Court of Philadelphia Municipal Court Number: 9. The Court of Common Pleas docket number: 10. Offense Tracking Number (OTN): 11. The date on complaint, or the date of arrest, and if available, the criminal justice agency that made the arrest: 12. The specific charges, as they appear on the charging document, to be subject to limited access and applicable dispositions (attach additional sheets if needed): 13. If the sentence includes a fine, costs, or restitution, whether the amount due has been paid: 14. This case qualifies for a limited access order and none of the exceptions under 18 Pa.C.S. § 9122.1(b) are applicable. 15. The reason(s) for this order for limited access: 16. The criminal justice agencies upon which certified copies of the order shall be served: American LegalNet, Inc. www.FormsWorkFlow.com