In the Court of Common Pleas County of Judicial District Commonwealth of Pennsylvania v ______________________ Docket No Petition for Order for Limited Access Pursuant to Pa.R.Crim.P. 791 AND NOW, the petitioner avers the following and requests that this petition for order for limited access pursuant to Pa.R.Crim.P. 791 be granted for the reasons set forth below. PETITIONER INFORMATION Full Name: Address: DOB: Alias(es): Social Security Number: CASE INFORMATION List the 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: Judge: Address: List name and mailing address of the affiant as shown on the complaint, if available: Name of Affiant: Address: Court of Common Pleas, Philadelphia Municipal Court or Magisterial District Docket Number: Date of Arrest or Complaint: Name of Arresting Agency: OTN: List specific charges, as they appear on the charging document, to be subject to limited access 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 order for limited access (please attach additional sheet(s) of paper if necessary): Yes No I have attached a copy of my Pennsylvania State Police Criminal History Report obtained within 60 days before filing this petition. I have not attached a copy of my Pennsylvania State Police Criminal History Report because the attorney for the Commonwealth waives this requirement. I, the undersigned petitioner, aver that above case qualifies for a limited access order and none of the exceptions under 18 Pa.C.S. § 9122.1(b) are applicable. I, the undersigned petitioner, aver 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 Rev 11/1/2016 __________________ Date American LegalNet, Inc. www.FormsWorkFlow.com