STATE OF LOUISIANA JUDICIAL DISTRICT FOR THE PARISH OF ______________________________ No.: _____________Division: "_______" State of Louisiana vs. _______________________________________________________ MOTION FOR EXPUNGEMENT NOW INTO COURT comes mover, who provides the court with the following information in connection with this request: I.DEFENDANT INFORMATION NAME: ___________________________________________________________ (Last, First, MI) DOB: ________/______/_______ (MM/DD/YYYY) GENDER _____ Female _____Male SSN (last 4 digits): XXX-XX-________ RACE: _________________ DRIVER LIC.# _________________ ARRESTING AGENCY: __________________________________________ SID# (if available): _________________ ARREST NUMBER (ATN): _________________ AGENCY ITEM NO. _________________ Mover is entitled to expunge the record of his arrest/conviction pursuant to Louisiana Code of Criminal Procedure Article 971 et seq. and states the following in support: II.ARREST INFORMATION 1. Mover was arrested on _______/______/_______ (MM/DD/YYYY) 2. _____ YES _____ NO A supplemental sheet with arrests and/or convictions is attached after page 2 of this Motion. 3. Mover was: _____ YES _____ NO Arrested, but it did not result in conviction _____ YES _____ NO Convicted of and seeks to expunge a misdemeanor _____ YES _____ NO Convicted of and seeks to expunge a felony _____ YES _____ NO Convicted but determined to be factually innocent and entitled to compensation for a wrongful conviction pursuant to the provisions of R.S. 15:572.8. 4. Mover was booked and/or charged with the following offenses: (List each offense booked and charged separately. Attach a supplemental sheet, if necessary.) ____ Yes ____ No ARRESTS THAT DID NOT RESULT IN CONVICTION NO. 1 La. Rev. Stat. Ann. § _______ : ________ Name of the offense __________________ ( ) Time expired for prosecution__________________ (MM/DD/YYYY) ( ) Not prosecuted for any offense arising out of this charge. ( ) Pre-trial Diversion Program. ( ) DWI Pre-Trial Diversion Program and 5 years have elapsed since the date of arrest. ( ) Charge dismissed ( ) Found not guilty/judgment of acquittal NO. 2 La. Rev. Stat. Ann. § _______ : ________ Name of the offense __________________ ( ) Time expired for prosecution__________________ (MM/DD/YYYY) ( ) Not prosecuted for any offense arising out of this charge. ( ) Pre-trial Diversion Program. ( ) Charge dismissed ( ) Found not guilty/judgment of acquittal NO. 3 La. Rev. Stat. Ann. § _______ : ________ Name of the offense __________________ ( ) Time expired for prosecution__________________ (MM/DD/YYYY) ( ) Not prosecuted for any offense arising out of this charge. ( ) Pre-trial Diversion Program. ( ) Charge dismissed ( ) Found not guilty/judgment of acquittal ____ Yes ____ No MISDEMEANOR CONVICTIONS NO. 1 La. Rev. Stat. Ann. § _______ : ________ Name of the offense _________________ ( ) Conviction set aside/dismissed _____/____/_______ pursuant to C.Cr.P. Art. 894(B) (MM/DD/YYYY) ( ) More than 5 years have passed since completion of sentence. NO. 2 La. Rev. Stat. Ann. § _______ : ________ Name of the offense _________________ ( ) Conviction set aside/dismissed _____/____/_______ pursuant to C.Cr.P. Art. 894(B) (MM/DD/YYYY) ( ) More than 5 years have passed since completion of sentence. ____ Yes ____ No FELONY CONVICTIONS NO. 1 La. Rev. Stat. Ann. § _______ : ________ ( ) Conviction set aside/dismissed _____/____/_______ pursuant to C.Cr.P. Art. 893(E)(MM/DD/YYYY) ( ) More than 10 years have passed since completion of sentence ( ) Received a first offender pardon for an eligible offense NO. 2 La. Rev. Stat. Ann. § _______ : ________ ( ) Conviction set aside/dismissed _____/____/_______ pursuant to C.Cr.P. Art. 893(E)(MM/DD/YYYY) ( ) More than 10 years have passed since completion of sentence ( ) Received a first offender pardon for an eligible offense ____ Yes ____ No OPERATING A MOTOR VEHICLE WHILE INTOXICATED CONVICTIONS Mover has attached the following: ( ) A copy of the proof from the Department of Public Safety and Corrections, office of motor vehicles, that it has received from the clerk of court a certified copy of the record of the plea, fingerprints of the defendant, and proof of the requirements set forth in C.Cr.P. Art. 556, which shall include the defendant's date of birth, last four digits of social security number, and driver's license number 5. Mover has attached to this Motion the following pertinent documents: □ Criminal Background Check from the La. State Police/Parish Sheriff dated within the past 60 days (required). □ Bill(s) of Information (if any). □ Minute entry showing final disposition of case (if any). □ Certification Letter from the District Attorney for fee waiver (if eligible). □ Certification Letter from the District Attorney verifying that the applicant has no convictions or pending applicable criminal charges in the requisite time periods. □ Certification Letter from the District Attorney verifying that the charges were refused. □ Certification Letter from the District Attorney verifying that the applicant did not participate in a pretrial diversion program. □ A copy of a first offender pardon. □ A copy of the order waiving the sex offender registration and notification requirements. □ A copy of the court order determination of factual innocence and order of compensation for a wrongful conviction pursuant to the provisions of R.S. 15:572.8 if applicable. The Mover prays that if there is no objection timely filed by the arresting law enforcement agency, the district attorney's office, or the Louisiana Bureau of Criminal Identification and Information, that an order be issued herein ordering the expungement of the record of arrest and/or conviction set forth above, including all photographs, fingerprints, disposition, or any other such information, which record shall be confidential and no longer considered a public record, nor be made available to other persons, except a prosecutor, member of a law enforcement agency, or a judge who may request such information in writing, certifying that such request is for the purpose of prosecuting, investigating, or enforcing the criminal law, for the purpose of any other statutorily defined law enforcement or administrative duties, or for the purpose of the requirements of sex offender registration and notification pursuant to the provisions of R.S. 15:541 et seq. or as an order of this Court to any other person for good cause shown, or as otherwise authorized by law. If an "Affidavit of No Opposition" by each agency named herein is attached hereto and made a part hereof, Defendant requests that no contradictory hearing be required and the Motion be granted ex parte. Respectfully submitted, ____________________________________ Signature of Attorney for Mover/Defendant ____________________________________ Attorney for Mover/Defendant Name ____________________________________ Attorney's Bar Roll No. ____________________________________ Address ____________________________________ City, State, ZIP Code ____________________________________ Telephone Number If not represented by counsel: ____________________________________ Signature of Mover/Defendant ____________________________________ Mover/Defendant Name ____________________________________ Address ____________________________________ City, State, ZIP Code ____________________________________ Telephone Number
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