(FOR TBI USE ONLY) State Identification Number: (FOR TBI USE ONLY) FBI Identification Number: ORDER FOR THE EXPUNGEMENT OF CRIMINAL OFFENDER RECORD (PLEASE PRINT OR TYPE) State of Tennessee vs Circuit Docket Number Date Original Case was filed in Clerk222s Office General Sessions Docket Number In the Court of County, Tennessee at On the Motion or Petition of Defendant/Arrest Information: Disposition Information: The defendant named above is entitled to have all PUBLIC RECORDS relating to the offenses listed above expunged according to the Tennessee Code Annotated provision marked below: It is ordered that all PUBLIC RECORDS relating to such offense above referenced be expunged and immediately destroyed upon payment of all costs to clerk and that no evidence of such records pertaining to such offense be retained by any municipal, county, or state agency, except non-public confidential information retained in accordance with T.C.A. 247 10-7-504 and T.C.A. 247 38-6-118. APPROVED FOR ENTRY Form EX-1 (Rev. 2003) Final Charge 1 Final Charge 2 Final Charge 3 Final Disposition Diversion Date (if applicable) Defendant (name used at time of arrest) Race Sex Date of Birth Arresting Agency OCA# Date of Arrest Charge 1(As shown on arrest fingerprint card) SSN# Charge 2(As shown on arrest fingerprint card) Charge 3(As shown on arrest fingerprint card) Provision relating to Adults: Provisions relating to Juveniles: Charge has been dismissed (T.C.A. 247 40-32-101) Petition alleging delinquency not filed (T.C.A. 247 37-1-155) No true bill returned by Grand Jury (T.C.A. 247 40-32-101) Proceedings dismissed after petition is filed or the case transferred to Juvenile Verdict of not guilty returned by jury (T.C.A. 247 40-32-101 Court as provided in T.C.A. 247 37-1-109 (T.C.A. 247 37-1-155) Conviction which has by appeal been reversed (T.C.A. 247 40-32-101) Adjudicated not to be a delinquent child (T.C.A. 247 37-1-155) Nolle Prosequi entered in case (T.C.A. 247 40-32-101) Child has reached eighteen (18) years of age and there is no record that he Successful completion of all probation provisions and proceedings committed a criminal offense after reaching sixteen (16) years of age, unless against defendant have been discharged by the court such fingerprints were obtained on alleged charge which if committed by an (T.C.A. 247 40-35-313) adult would be a felony (T.C.A. 247 37-1-155) Suspension of prosecution pursuant to T.C.A. 247 40-15-105 Passage of six (6) months from date of liquor law violations defined by T.C.A. 247 57-3-412(a)(3)(c) or T.C.A. 247 57-5-301(e)(3) Entered this day of , Defendant/Attorney for Defendant District Attorney General Judge American LegalNet, Inc. www.FormsWorkFlow.com