In the Court of Common Pleas County of [Name] Judicial District Commonwealth of Pennsylvania v ______________________ Docket No: CP-20 Petition for Expungement Pursuant to Pa.R.Crim.P. 490 AND NOW, the petitioner avers the following and requests that this petition for expungement pursuant to Pa.R.Crim.P. 490 be granted for the reasons set forth below. PETITIONER INFORMATION Full Name: Address: DOB: Alias(es): Social Security Number: CASE INFORMATION List name, address of Judge of the Magisterial District or Philadelphia Municipal Court who accepted the guilty plea or heard the case: Address: Judge: Magisterial District Court Number: Philadelphia Municipal Court or Magisterial District Docket Number: Name of Arresting Agency: Date of Arrest: List name and mailing address of the affiant as shown on the complaint or citation, if available: Name of Affiant: Address: Date on Citation or Complaint: List specific charges, as they appear on the charging document, to be expunged and the disposition of each charge (please attach additional sheet(s) of paper if necessary): PA Statute (Title) Section Subsection Statute Description Counts Grade Disposition If the sentence imposed included a fine, costs or restitution, has the amount due been paid? List the reason(s) for the expungement (please attach additional sheet(s) of paper if necessary): Yes No I have attached a copy of my Pennsylvania State Police Criminal History which I have obtained within 60 days before filing this petition. I have not attached a copy of my Pennsylvania State Police Criminal History. State reason(s) below: When this petition is filed with the Clerk of Courts, the petitioner shall serve a copy upon the attorney for the Commonwealth. I, the undersigned petitioner, avers that the facts set forth in this petition are true and correct to the best of my personal knowledge or information and belief, and are made subject to the penalties of unsworn falsification to authorities under 18 Pa.C.S § 4904. _________________________________ Signature of Petitioner AOPC Form Updated Rev 03/09/12 __________________ Date American LegalNet, Inc. www.FormsWorkFlow.com