PETITION OR MOTION FOR EXPUNGEMENT Commonwealth of Virginia Va. Code § 18.2-186.5, 19.2-392.2 Case No. ........................................................................................ ........................................................ ........................................................ Underlying Case No(s). [ ] Circuit Court [ ] General District Court ................................................................................................... [ ] Juvenile & Domestic Relations District Court CITY OR COUNTY ............................................................................................................................................................................................................................................................................... STREET ADDRESS OF COURT .............................................................................................................................. NAME OF PETITIONER/MOVANT v. COMMONWEALTH OF VIRGINIA CHECK ONE: [ ] I petition the court to expunge the police and court records relating to the charge(s) below based on subsection B of § 19.2-392.2. My name or other identification has been used without my consent or authorization by another person who has been charged or arrested using such name or identification. The identification used without my consent or authorization was: ...................................................................................................................................................................................................................................................................... The name of the person using my identification is: .................................................................................................................... [ ] Name Unknown OR [ ] I move the court to expunge the police and court records relating to the charge(s) in the summons, warrant, indictment or presentment, based on subsection H of § 19.2-392.2. I was improperly arrested or charged pursuant to the aforesaid charging document and it has been dismissed because the court found that I was not the person named in the summons, warrant, indictment, or presentment. COMPLETE THE FOLLOWING: My date of birth is: ............................................................................. The last four digits of my social security number are: ..................................... Specific charge(s) to be expunged: ........................................................................................................................................................................................................ .................................................................................................................................................................................................. Date of final disposition of charge(s): Court disposing of charge(s): Underlying Case No(s). ................................................................................................................................................................................................................... .............................................................................................................................................................................................................................. [ ] A copy of the warrant, summons indictment, or presentment is attached to this PETITION/MOTION. On this basis, I request that the police and court records relating to this charge be expunged and that a copy of any order of expungement be forwarded to the Department of State Police pursuant to subsection I of § 19.2-392.2. I have included with this PETITION/MOTION one complete set of my fingerprints obtained from a law-enforcement agency to accompany such order. ....................................................................... DATE _____________________________________________________ SIGNATURE OF PETITIONER/MOVANT Filed by: [ ] Petitioner/Movant [ ] Attorney for Petitioner/Movant ______________________________________________________ SIGNATURE ADDRESS/TELEPHONE NUMBER OF [ ] PETITIONER/MOVANT [ ] ATTORNEY ............................................................................................................................................................................................................................................................. State of ..................................................................................................... Acknowledged, subscribed and sworn to before me this ....................................................................... NOTARY REGISTRATION NUMBER [ ] City [ ] County of .................................................................................................. ................. ............................... day of .................................................................................... , 20 [ ] CLERK [ ] NOTARY PUBLIC ______________________________________________________________ (My commission expires: ......................................... ) FORM DC-363 MASTER 07/11 American LegalNet, Inc. www.FormsWorkFlow.com