" STATE OF LOUISIANA JUDICIAL DISTRICT FOR THE PARISH OF ______________________________ No.: ______________Division: "_______" State of Louisiana vs. _______________________________________________________ CERTIFICATION OF FEE WAIVER To be completed by defendant and submitted to the District Attorney's Office prior to filing. Append completed form to Motion of Expungement at filing only if eligible. DEFENDANT NAME DATE OF BIRTH SSN (last 4 digits)# XXX-XX- DATE OF ARREST DOCKET NUMBER CHARGE In accordance with Louisiana Code of Criminal Procedure Article 983, the Office of the District Attorney has reviewed the available databases and determined that (Check all that apply. To be completed by authorized personnel from the District Attorney's Office and returned within 15 days to defendant.) : □ The arrestee listed above has NO FELONY CONVICTIONS. AND □ The arrestee listed above has NO PENDING FELONY CHARGES UNDER A BILL OF INDICTMENT OR INFORMATION. AND □ The arrestee listed above WAS ACQUITTED after trial of all charges derived from the arrest listed above, including any lesser and included offense. OR □ The arrestee listed above WAS NOT PROSECUTED WITHIN THE TIME LIMITATIONS prescribed in Chapter 1 of Title XVII of the Code of Criminal Procedure and the arrestee did not participate in a pretrial diversion program for the arrest listed above. OR □ The case involving the arrestee listed above was dismissed or the district attorney declined to prosecute the case prior to the time limitations prescribed in Chapter 1 of Title XVII of the Code of Criminal Procedure, and the arrestee did not participate in a pretrial diversion program. OR □ The arrestee listed above has been determined to be factually innocent and entitled to compensation for a wrongful conviction pursuant to the provisions of R.S. 15:572.8. OR □ The arrestee listed above is a juvenile who has successfully completed any juvenile drug court program and is exempt from fees pursuant to Code of Criminal Procedure Article 983(G). _____________________________________ District Attorney or his designee - Print Name _______________________________________________________, 20____" District Attorney or his designee - SignatureDate
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