REQUEST FOR CORRECTION OF AN ELECTRONIC CASE RECORD (A separate request form must be submitted for each case) Requestor Information Name: Address: Attorney No. (if applicable): Phone Number: Email Address: Fax Number: Case caption of the electronic case record: Docket number of the electronic case record: _____________________________________________________________________________________________ Set forth in specificity the information that appears on the electronic case record referenced above which you believe to be in error. (Attach additional sheets if necessary). Set forth in specificity sufficient facts that support your contention that the information in question is in error, including supporting documentation. (Attach additional sheets if necessary). I, _________________________________, verify that the facts set forth in this form are true and correct to the best of my knowledge, information and belief. This statement is made subject to the penalties of Section 4904 of the Crimes Code (18 Pa.C.S. � 4904) relating to unsworn falsification to authorities. ___________________________________ Signature of Requestor _______________________________ Date NOTE: If you are seeking to correct a data error in an electronic case record of a court of common pleas or Philadelphia Municipal Court (i.e., a CPCMS record), this form must be submitted to the appropriate clerk of courts. If you are seeking to correct the data error in an electronic record of a magisterial district court (i.e., a MDJS record), this form must be filed with the magisterial district court presiding over the case. You must also provide a copy of this completed form to all parties on the case, the appropriate district court administrator and AOPC. Addresses for district court administrators, clerk of courts and magisterial district judges may be found on the UJS Web site under the "Electronic Case Record" section at: http://www.pacourts.us/T/AOPC/PublicAccessPolicy.htm. Copies to the AOPC should be sent to: Administrative Office of Pennsylvania Courts ATTN: Section 6.00 Request 601 Commonwealth Avenue PO Box 61260 Harrisburg, PA 17106-1260 Phone: 717-231-3300 Fax: 717-231-9566 American LegalNet, Inc. www.FormsWorkFlow.com For Court Use Only Please be advised that your request was received on ___/___/___. In accordance with the Electronic Case Record Public Access Policy of the Unified Judicial System, please be advised that: this request is being returned to you because it does not contain sufficient information to evaluate your request. No further action will be taken unless you resubmit the request with additional information. this request is being returned to you because it does not concern an electronic case record. No further action will be taken on this matter. it was determined an error existed in the electronic case record, and the information has been corrected. it was determined an error does not exist in the electronic case record. an additional period of time not exceeding 30 business days is necessary to complete a review of your request. Comments: ______________________________________ Signature ________________________________ Date If an additional period of time not exceeding 30 days was necessary to complete the review of this request, please be advised that: this request is being returned to you because it does not contain sufficient information to evaluate your request. No further action will be taken unless you resubmit the request with additional information. this request is being returned to you because it does not concern an electronic case record. No further action will be taken on this matter. it was determined an error existed in the electronic case record, and the information has been corrected. it was determined an error does not exist in the electronic case record. Comments: __________________________________ Signature ________________________________ Date For Use by Requestor If you wish to seek review of the decision set forth above, please complete this section and submit this entire form to the District Court Administrator of the county where the electronic case record information originated within 10 business days of notification of the decision. I,_________________________________, request that a review of the decision set forth above be made. __________________________________ Signature ________________________________ Date American LegalNet, Inc. www.FormsWorkFlow.com