Fill - Free fillable IN RE THE PETITION FOR EXPUNGEMENT OF RECORDS (Indiana Legal Help) PDF form

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STATE OF INDIANA IN THE __________________ _________________ COURT

COUNTY OF __________________ CAUSE NO. ____________________________________

IN RE THE PETITION FOR EXPUNGEMENT

OF RECORDS OF ARREST, CRIMINAL CHARGES,

OR JUVENILE DELINQUENCE ALLEGATIONS OF:

___________________________________

Petitioner

APPEARANCE BY UNREPRESENTED PERSON IN EXPUNGEMENT MATTER

1. My name is _________________________________ and I am the Petitioner in this case I am

not represented by a lawyer.

2. My current address is:

Email address:

☐ I will accept service at the above email address.

Phone:

Fax:

OR, if in a related case, you have used the Attorney General confidential address, you may check

the box below:

☐ Attorney General confidential address

3. This is an XP case type as defined in Administrative Rule 8(B)(3).

4. There are related cases: (If yes, please indicate below)

☐ Yes

☐ No

Caption and case number of related cases:

Caption: Case No.:

____________

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Caption: Case No.:

Additional information as required by local rule:

Signature

CERTIFICATE OF SERVICE

☐I hereby certify that I sent a copy of this document on ________________________ by first-

class U.S. mail, postage prepaid or via hand-delivery to the _______________________ County

Prosecutor at the following address:

______________________________

☐I hereby certify that on _________________________ a copy of this document was served

upon the _________________________ County Prosecutor via the Indiana E-filing System.

______________________________

Signature

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STATE OF INDIANA IN THE __________________ _______________ COURT

COUNTY OF _________________ CAUSE NO: ______________________________________

☐ An exhibit listing additional case numbers is attached

IN RE THE PETITION FOR Related Criminal Cause Numbers:

EXPUNGEMENT OF CONVICTION ____________________________________________

RECORDS OF: ____________________________________________

_____________________________ ____________________________________________

Petitioner ____________________________________________

VERIFIED PETITION FOR EXPUNGEMENT OF CONVICTION RECORDS PURSUANT TO

I.C. 35-38-9

Comes now the Petitioner, ______________________________, in person and duly sworn upon

their oath, and does file this Petition for Expungement/Sealing of Records under the provisions of IC 35-

38-9 et. seq. and would respectfully request that the Court grant said petition and find that the convictions

listed in this petition be expunged pursuant to statute and that access to these convictions be expunged in

accordance with IC 35-38-9-6 or IC 35-38-9-7. In support thereof, the Petitioner would swear and affirm to

the following factual information:

INFORMATION PERTAINING TO ALL EXPUNGEMENT MATTERS

1. That Petitioner’s full name is ________________________________________, and that Petitioner

has used the following other names or aliases:

______________________________________________________________________________________

2. That Petitioner’s date of birth is ___________________________; Petitioner’s Social Security

Number is XXX-XX-_________; and Petitioner’s driver’s license number is _______________________.

3. Since the commission of the first criminal offense addressed in this Petition, Petitioner has resided

at the following addresses:

______________________________________________________________________________________

☐ Petitioner has attached an additional page, marked as “Exhibit ,” to the end of this petition that

contains a list of the remaining addresses where petitioner has resided since the first criminal offense

addressed in this petition.

4. Petitioner affirms, under oath and subject to penalties for the crime of Perjury that, to the best of

their knowledge, there are no criminal investigations and/or charges pending against them in any

jurisdiction.

5. The following is a list of all criminal convictions entered against Petitioner (including court; cause

number; title and class/level of offense(s) on which conviction was entered; date offense was committed;

date of conviction; appellate cause number (if applicable); and date of appellate opinion (if applicable)):

____________

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a.

b.

c.

d.

☐ Petitioner has attached an additional page, marked as “Exhibit ,” to the end of this petition listing

other criminal convictions that have been entered against them.

6. Petitioner acknowledges that they understand that IC 35-38-9-9(i) allows them to file only one

petition for expungement during their lifetime. Petitioner certifies that they have made a good faith effort

to remember and obtain records for all of their convictions. At the time of filing this petition, Petitioner

has no knowledge of any ___________________ County convictions other than those that are addressed by

this petition. __________ (Petitioner’s initials)

7. The following is a list of petitions to address convictions that are eligible for expungement under

I.C. § 35-38-9-2 through 5 that the Petitioner has filed or will be filing in other Indiana counties:

a. ________________________________________________________________________________

________________________________________________________________________________

b. ________________________________________________________________________________

________________________________________________________________________________

☐ Petitioner has attached an additional page, marked as “Exhibit ,” to the end of this

petition listing additional expungement petitions filed in other Indiana counties.

c. Petitioner has served a copy of this petition upon the Prosecuting Attorney in accordance with the

Indiana Rules of Trial Procedure.

---

Take out this page and insert your

conviction Facts pages (from the

Conviction Insert Forms)

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ADDITIONAL INFORMATION SUBMITTED BY PETITIONER

1. Petitioner submits the following additional information to be considered by this Court in support of

the Petition:

a. ________________________________________________________________________________

________________________________________________________________________________

b. ________________________________________________________________________________

________________________________________________________________________________

c. ________________________________________________________________________________

________________________________________________________________________________

The following documents are attached to this Petition as exhibits:

☐ A certified copy of a limited criminal history transcript from the Indiana State Police.

☐ A copy of the chronological case summary for the following cause numbers showing payment

of all fines, fees and court costs:

________________________________________________________________________________

☐ Other documentation as listed here:

________________________________________________________________________________

WHEREFORE, Petitioner respectfully requests this Court grant this Petition and ORDER:

1. As to Expungement Matters ___________________________, the expungement of Petitioner’s

conviction records in accordance with I.C. 35-38-9-6, specifically:

a. The following agencies and entities shall be prohibited from releasing Petitioner’s records or

information in Petitioner’s records, including but not limited to conviction records, arrest records,

dismissed charge records, not-guilty records, and records of collateral actions, that related to the

expunged convictions or that relate to the cause number of the expunged convictions, to anyone

without a court order, other than a law enforcement officer acting in the court of the officer’s official

duty:

i. The Indiana Department of Corrections;

ii. The Indiana Bureau of Motor Vehicles;

iii. Each law enforcement agency who incarcerated, provided treatment for, or provided other

services for the person under an order of the court; and

iv. Each person or entity who incarcerated, provided treatment for, or provided other services for

the person under an order of the court.

b. The Indiana State Police Central Repository for Criminal History Information is ordered to seal all

Petitioner’s records for expunged convictions and records for all other matters related to the cause

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number of expunged conviction(s). This includes but is not limited to conviction records, arrest

records, dismissed charge records, not-guilty records, and records of collateral actions, that related to

the expunged convictions or that relate to the cause number of the expunged convictions. Thus, the

Central Repository must seal all of Petitioner’s conviction records, dismissed charge records, not

guilty records, arrest records, records of collateral actions, and any other records related to the cause

number of the expunged conviction(s). Central Repository is also prohibited from disclosing these

records to anyone except:

i. a prosecuting attorney, if:

(a) authorized by a court order; and

(b) needed to carry out the official duties of the prosecuting attorney;

ii. a defense attorney, if:

(a) authorized by a court order; and

(b) needed to carry out the professional duties of the defense attorney;

iii. a probation department, if:

(a) authorized by a court order; and

(b) necessary to prepare a presentence report; and

iv. the Federal Bureau of Investigation and the Department of Homeland Security, if disclosure

is required to comply with an agreement relating to the sharing of criminal history

information;

v. the:

(a) supreme court;

(b) members of the state board of law examiners; and

(c) executive director of the state board of law examiners; and

(d) employees of the state board of law examiners, in accordance with rules adopted

by the state board of law examiners;

for the purposes of determining whether an applicant possesses the necessary good moral

character for admission to the bar; and

vi. a person required to access expunged records to comply with the Secure and Fair

Enforcement for Mortgage Licensing Act (12 U.S.C. 5101 et seq.) or regulations adopted

under the Secure and Fair Enforcement for Mortgage Licensing Act.

vii. the bureau of motor vehicles, the Federal Motor Carrier Administration, and the

Commercial Drivers License Information System (CDLIS), if disclosure is required to

comply with IC 9-24-6-2(d) relating to reporting a conviction for a violation of a traffic

control law.

c. The Clerk of the Appellate Courts shall be notified to seal any records in the Clerk’s possession that

relate to the conviction in a manner consistent with I.C. 35-38-9-6(c):

i. redact the opinion or memorandum decision as it appears on the computer gateway

administered by the office of technology so that it does not include the petitioner’s name (in

the same manner that opinions involving juveniles are redacted); and

ii. provide a redacted copy of the opinion to any publisher or organization to whom the opinion

or memorandum decision is provided after the date of the order of expungement.

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d. Except as provided in I.C. 35-38-9-6(c) and (d), the records of the sentencing court, a juvenile

court, the Court of Appeals or Indiana, and the Indiana Supreme Court concerning Petitioner shall

be permanently sealed;

2. As to Expungement Matters _________________________, the expungement of Petitioner’s

conviction records in accordance with I.C. 35-38-9-7, specifically that:

a. Petitioner’s conviction records under the listed cause numbers shall be expunged in accordance

with I.C. 35-38-9-7:

i. Court records and other public records relating to the arrest, conviction, or sentence of

Petitioner that have been marked expunged shall remain public records. However, the Court

now orders that those records be clearly and visibly marked or identified as being expunged.

ii. The following agencies and entities in possession of records that relate to the conviction

ordered to be marked as expunged shall add an entry to Petitioner’s record of arrest,

conviction, or sentence in the criminal history database stating that the records are marked

as expunged:

(a) The Indiana Department of Correction;

(b) The Indiana Bureau of Motor Vehicles;

(c) Each law enforcement agency who incarcerated, provided treatment for, or provided

other services for the person under an order of the court; and

(d) Each person or entity who incarcerated, provided treatment for, or provided other

services for the person under an order of the court.

and grant all other relief just and proper in the premises.

AFFIRMATION

I AFFIRM, UNDER THE PENALTIES OF PERJURY, THAT THE FOREGOING

REPRESENTATIONS ARE TRUE AND ACCURATE.

____________________________________________

___________________________________, Petitioner

[Printed name]

CERTIFICATE OF SERVICE

The Petitioner hereby certifies that the foregoing pleadings have been served upon the following

persons or parties, via US First Class mail, electronic mail, facsimile transmission, or hand delivery on this

day _________________________________:

_______________________ County Prosecutor’s Office

Attn: _________________________________________

______________________________________________

____________________________________________

Signature of Petitioner

___________________________________, Petitioner

[Printed name]

_________________________________________

Phone: ___________________________________ Email: ______________________________________

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Form ACR (Access to Court Records)

STATE OF INDIANA IN THE __________________ _________________ COURT

COUNTY OF __________________ CAUSE NO. ____________________________________

IN RE THE PETITION FOR EXPUNGEMENT

OF RECORDS OF ARREST, CRIMINAL CHARGES,

OR JUVENILE DELINQUENCE ALLEGATIONS OF:

___________________________________

Petitioner

Notice of Exclusion of Confidential Information from Public Access

(FILED WITH TRIAL COURT CLERK)

Contemporaneous with the filing of this notice, _______________________________ has filed

confidential information under the Indiana Rules on Access to Court Records. ___________________________,

provides this notice that the confidential information is to remain excluded from public access in accordance

with the authority listed below:

Name or description of document

ACR grounds for exclusion

Confidential Information Form listing

Petitioner’s full Social Security Number

Access to Court Records Rule 5

________________________________

Signature

CERTIFICATE OF SERVICE

☐I hereby certify that I sent a copy of this document on ________________________ by first-

class U.S. mail, postage prepaid or via hand-delivery to the _______________________ County

Prosecutor at the following address:

______________________________

☐I hereby certify that on _________________________ a copy of this document was served

upon the _________________________ County Prosecutor via the Indiana E-filing System.

______________________________

Signature

____________

Not Public Record

CONFIDENTIAL INFORMATION FORM

XP CAUSE NUMBER: __________________________________________________________

PETITIONER’S NAME: _________________________________________________________

PETITIONER’S FULL SOCIAL SECURITY NUMBER: _______________________________

ATTENTION CLERK: FOR SELF REPRESENTED LITIGANTS TREAT THIS FORM

AS IF IT IS PRINTED ON GREEN PAPER.

IF THIS DOCUMENT IS E-FILED, FILE THIS AS A CONFIDENTIAL DOCUMENT

Not Public Record

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NOT

PUBLIC RECORD

ST

ATE OF INDIANA IN THE __________________ _______________ COURT

CO

UNTY OF _________________ CAUSE NO: ______________________________________

☐ An exhibit listing additional case numbers is attached

IN

RE THE PETITION FOR Related Criminal Cause Numbers:

EXPUNGEMENT OF CONVICTION ____________________________________________

RECORDS OF: ____________________________________________

_____________________________ ____________________________________________

Petitioner ____________________________________________

FINDINGS AND ORDER GRANTING PETITIONER’S VERIFIED PETITION FOR EXPUNGEMENT OF

CONVICTION RECORDS PURSUANT TO I.C § 35-38-9

Pe

titioner, _________________________________, [by counsel, _____________________________________,]

filed this Verified Petition for Expungement of Conviction Records Pursuant to I.C. §35-38-9, and the State of Indiana, by

counsel,

☐ filed ☐ did not file its Response to Petitioner’s Verified Petition for Expungement.

Pe

titioner’s Verified Petition for Expungement seeks relief as provided by I.C. §35-38-9 for multiple cases arising

out of ___________________________ County, Indiana that resulted in convictions.

☐ Upon review of said Petition , ☐ and the State of Indiana’s Response, the Court finds that the State has

provided no legal basis upon which to state an objection to the Court’s granting of Petitioner’s Verified

Petition for Expungement/Sealing of Arrest Records.

☐ A hearing was held on _________________________________ regarding said Petition of which all

parties were given notice and during which all parties were given an opportunity to present evidence and

Arguments.

FINDINGS AS TO ALL EXPUNGEMENT MATTER:

The Court now finds by a preponderance of the evidence that:

1. Petitioner’s Verified Petition for Expungement complies with the requirements of I.C. § 35-38-9-8.

2. Consistent with the provisions of I.C. § 35-38-9-9(i) and except as provided in I.C. § 35-38-9-9Ij) and (k),

Petitioner has only filed one (1) Verified Petition for Expungement in their lifetime.

3. The following is a list of petitions to address convictions that are eligible for expungement under I.C. §

35-38-9-2 through 5 that the Petitioner has filed or will be filing in other Indiana counties:

a. ______________________________________________________________________________

______________________________________________________________________________

b. ______________________________________________________________________________

______________________________________________________________________________

☐ An additional page has been attached to the end of this petition, marked as

“Exhibit ,” listing additional expungement petitions filed in other Indiana counties.

4. No c

harges are currently pending against Petitioner.

____________

Take out this page and insert your

conviction Findings pages (from the

Conviction Insert Forms)

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NOT PUBLIC RECORD

ORDER

It is therefore ORDERED, ADJUDGED, and DECREED that Petitioner’s Verified Petition for Expungement is

GRANTED as to EXPUNGEMENT MATTERS: __________________________________ and DENIED as to

EXPUNGEMENT MATTERS: ______________________________________________. All information necessary to

identify particular agency records that are to be expunged pursuant to this Order has been included in Exhibit A attached

to this Order.

1. As to all EXPUNGEMENT MATTERS for which an expungement is granted: The following provisions of

this Order shall apply to all except those person or entities specifically listed to whom sealed records may be

disclosed pursuant to paragraph 2(b) of this Order:

a. Except as provided in I.C. §35-38-9-6(f), Petitioner’s civil rights shall be restored, including the right to

vote, to hold public office, to be a proper person under IC §35-47-1-7(2), and to serve as a juror.

b. It is unlawful discrimination for any person to:

i. suspend;

ii. expel;

iii. refuse to employ;

iv. refuse to admit;

v. refuse to grant or renew a license, permit, or certificate necessary to engage in any activity,

occupation, or profession; or

vi. otherwise discriminate against;

Petitioner because of a conviction or arrest record expunged or sealed under this Order.

c. In any application for employment, a license, or other right or privilege, Petitioner may be questioned

about a previous criminal record only in terms that exclude expunged convictions or arrests.

d. Petitioner shall be treated as if Petitioner had never been convicted of the offense. However, upon

subsequent arrest or conviction for an unrelated offense, the expunged conviction: (1) may be considered

by the Court in determining the sentence imposed for the new offense; (2) is a prior unrelated conviction

for the purposes of a habitual offender enhancement and enhancing the new offense based on a prior

conviction; and (3) may be admitted as evidence in the proceeding for a new offense as if the conviction

had not been expunged.

e. If Petitioner is required to register as a sex offender based on the commission of a felony that has been

expunged in accordance with this Order:

i. the expungement does not affect the operation of the sex offender registry website, any person’s

ability to access Petitioner’s records, records required to be maintained concerning sex or violent

offenders, or any registration requirement impose don the Petitioner; and

ii. the expunged conviction must be clearly marked as expunged on the sex offender registry

website.

f. Expungement of any conviction records in accordance with this order does not affect any existing or

pending driver’s license suspension.

g. Nothing in this Order should be construed to prevent the Indiana Bureau of Motor Vehicles from

reporting information about conviction for a violation of a traffic control law to the Commercial Drivers

License Information System (CDLIS) in accordance with I.C. §9-24-6-2(d).

NOT PUBLIC RECORD

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NOT PUBLIC RECORD

2. As to EXPUNGEMENT MATTERS ____________________________________________________

of Petitioner’s records, including but not limited to conviction records, arrest records, dismissed charge records,

not-guilty records, and records of collateral actions that relate to the expunged convictions or that relate to the

cause number of the expunged convictions under the following Cause Numbers, are expunged in accordance with

Indiana Code §35-38-9-6:

___________________________________________________________________________________________

a. Records in possession of state and local agencies and service providers: The following agencies and

entities are hereby prohibited from releasing Petitioner’s record including but not limited to conviction

records, arrest records, dismissed charge records, not-guilty records, and records of collateral actions that

relate to the expunged convictions or that relate to the cause number of the expunged convictions to

anyone without a court order, other than a law enforcement officer acting in the court of the officer’s

official duty:

i. The Indiana Department of Corrections;

ii. The Indiana Bureau of Motor Vehicles, except as provided in paragraph 1(g) of this Order,

iii. Each law enforcement agency who incarcerated, provided treatment for, or provided other

services for the person under an order of the court, including:

(a) ___________________________________________________;

(b) ___________________________________________________; and

iv. Each person or entity who incarcerated, provided treatment for, or provided other services for the

person under an order of the court, including:

(a) ___________________________________________________;

(b) ___________________________________________________.

b. Records in possession of the Indiana State Police Central Records Repository: In accordance with

I.C. §35-38-9-6(a)(2), the Indiana State Police Central Repository for Criminal History Information is

ordered to seal all of Petitioner’s records for Cause Number

_________________________________________. This includes, but is not limited to, conviction

records, arrest records, dismissed charge records, not-guilty records, and records of collateral actions that

relate to the expunged convictions or any other matters that relate to this cause number. The Central

Repository is also prohibited from disclosing these records to anyone except:

i. a prosecuting attorney, if:

(a) authorized by a court order; and

(b) needed to carry out the official duties of the prosecuting attorney;

ii. a defense attorney, if:

(a) authorized by a court order; and

(b) needed to carry out the professional duties of the defense attorney

iii. a probation department, if:

(a) authorized by a court order; and

(b) necessary to prepare a presentence report; and

iv. the Federal Bureau of Investigation and the Department of Homeland Security, if

disclosure is required to comply with an agreement relating to the sharing of criminal

history information;

v. the:

(a) supreme court;

(b) members of the state board of law examiners;

(c) executive director of the state board of law examiners; and

(d) employees of the state board of law examiners, in accordance with rules adopted by

the state board of law examiners;

NOT PUBLIC RECORD

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NOT PUBLIC RECORD

for the purpose of determining whether an applicant possesses the necessary good moral

character for admission to the bar;

vi. a person required to access expunged records to comply with the Secure and Fair

Enforcement for Mortgage Licensing Act (12 U.S.C. 5101 et seq.) or regulations adopted

under the Secure and Fair Enforcement for Mortgage Licensing Act; and

vii. the Bureau of Motor Vehicles, the Federal Motor Carrier Administration, and the

Commercial Drivers License information System (CDLIS), if disclosure is required to

comply with IC §9-24-6-2(d) relating to reporting a conviction for a violation of a traffic

control law.

c. Records of the sentencing court, the juvenile court, the Court of Appeals and the Supreme Court:

Except as provided in IC §35-38-9-6(d), the records of the sentencing court, a juvenile court, the Court of

Appeals of Indiana, and the Indiana Supreme Court concerning Petitioner shall be permanently sealed.

d. As to court records stored under the following appellate/post conviction relief cause numbers:

_____________________________________________________________________________________

_______________________________________________________________________

the Clerk shall send a copy of this Order to the Indiana Clerk of the Appellate Courts, and Clerk of the

Appellate Courts shall:

i. redact any opinion or memorandum decision in which the Petitioner has been named as it

appears on the computer gateway administered by the office of technology so that it does

not include the Petitioner’s name (in the same manner by which opinions involving

juveniles are redacted); and

ii. provide a redacted copy of the opinion to any publisher or organization to whom the

opinion or memorandum decision is provided after the date of the order of expungement

e. The Clerk shall send a copy of this Order to all parties of record or their attorneys to the Indiana State

Police Central Repository for Criminal History, to the Indiana Department of Corrections, to the Indiana

Bureau of Motor Vehicles, and the following law enforcement agencies or entities that possess records

related to Petitioner’s conviction:

i. The _______________________ County Sheriff’s Department

ii. The local law enforcement agencies:

(a) _______________________________________;

(b) _______________________________________;

iii. All persons or entities who incarcerated, provided treatment for, or provided other

services for the person under an order of the court, including:

(a) _______________________________________;

(b) _______________________________________.

3. As to EXPUNGEMENT MATTERS ____________________________________________________

pertaining to records related to the following criminal and MC cause numbers:

___________________________________________________________________________________________

_______________________________________________________________

Petitioner’s conviction records shall be expunged in accordance with IC §35-38-9-7, specifically:

NOT PUBLIC RECORD

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NOT PUBLIC RECORD

a. All court records and other public records relating to the arrest, conviction, or sentence of Petitioner that

have been marked expunged shall remain public records. However, the Court now orders that those

records be clearly and visibly marked or identified as being expunged.

b. The following agencies and entities in possession of records that relate to the conviction ordered to be

marked as expunged shall add an entry to Petitioner’s record of arrest, conviction, or sentence in the

criminal history database stating that the records are marked as expunged:

i. The Indiana Department of Correction;

ii. The Indiana Bureau of Motor Vehicles;

iii. Each law enforcement agency who incarcerated, provided treatment for, or provided other

services for the person under an order of the court:

(a) __________________________________________;

(b) __________________________________________; and

iv. Each person or entity who incarcerated, provided treatment for, or provided other services for the

person under an order of the court, including:

(a) __________________________________________;

(b) __________________________________________.

c. The Clerk shall send a copy of this Order to all parties of record or their attorneys, to the Indiana State

Police Central Repository for Criminal History; to the Indiana Department of Correction, to the Indiana

Bureau of Motor Vehicles, and the following law enforcement agencies or entities that possess records

related to Petitioner’s conviction:

i. The _________________________ County Sheriff’s Department

ii. The local law enforcement agencies:

(a) __________________________________________

(b) __________________________________________

iii. All persons or entities who incarcerated, provided treatment for, or provided other services for the

person under an order of the court, including:

(a) __________________________________________

(b) __________________________________________

d. As to court records stored under the following appellate/post conviction relief cause numbers:

______________________________________________________________________________

the Clerk shall send a copy of this Order to the Indiana Clerk of Appellate Courts, and:

i. all court records and other public records relating to the arrest, conviction, or sentence shall

remain public records;

ii. the records shall be clearly and visibly marked or identified as being expunged.

SO ORDERED this ____________________________________________________.

__________________________________________

Judicial Officer

_____________________________________Court

___________________________ Room _________

Notice to be given by: ☐Court ☐Clerk ☐Other: _________________________________________

NOT PUBLIC RECORD

____________

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NOT PUBLIC RECORD

PROOF OF NOTICE

A copy of the entry was served either by mail to the address of record, deposited in the attorney’s distribution box,

or personally distributed to the following persons:

State of Indiana: ___________________________________________

Petitioner: ________________________________________________

Date of notice: _____________________________________________

Initial of person who notified parties: _______ Court _______ Clerk _______ Other

Distribution To:

☐ _______________________________________ Indiana State Police

Attorney for Petitioner Attn: Records Division

___________________________________________ 100 N Senate Ave., Room N301 (East)

___________________________________________ Indianapolis, IN 46204

☐ _______________________________________ Bureau of Motor Vehicles

Petitioner IGC North, Room 402

___________________________________________ 100 N Senate Ave.

___________________________________________ Indianapolis, IN 46204

_____________________ County Prosecutor’s Office Indiana Department of Correction

Attn:_______________________________________ Attn: Records Division

___________________________________________ 302 W. Washington Street, Room E-334

___________________________________________ Indianapolis, IN 46204

____________________County Sheriff’s Department Office of the Indiana Attorney General

___________________________________________ Indiana Government Center South, 5

th

Floor

___________________________________________ 302 W. Washington Street

Indianapolis, IN 46204

☐ ________________ County Clerk ☐ Clerk of the Appellate Courts

___________________________________________ 216 State House

___________________________________________ 200 West Washington Street

[check the ‘County Clerk’ box only if this ORDER Indianapolis, IN 46204

Applies to court records stored under a separate MC [check ‘Clerk of the Appellate Courts’ only if one or

Cause number that pertain to a PROBATION that of the expunged cases was appealed.]

was transferred to another county.]

Law Enforcement Agencies: ☐ Indiana Supreme Court

___________________________________________ Office of Judicial Administration

___________________________________________ Trial Court Technology

___________________________________________ 251 N. Illinois Street, Suite 700

___________________________________________ Indianapolis, IN 46204

___________________________________________ [check this address only if a NO CONTACT ORDER was issued

___________________________________________ in one or more of the expunged cases as a condition of BOND or

___________________________________________ PROBATION.]

NOT PUBLIC RECORD

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NOT PUBLIC RECORD

Law Enforcement Agencies (cont’d): Other persons or entities that are required to act

___________________________________________ under this order because they possess official records

___________________________________________ related to the expunged convictions:

___________________________________________ ___________________________________________

NOT PUBLIC RECORD

Take out this page and insert your

non-conviction Exhibit pages (from

the Conviction Insert Forms)

Attach a document to the back of the Petition

and Order listing the following information

for any additional cause numbers that did not

fit on the Petition.

Cause #

Court Room

Offense(s) where convicted

Class of Offense(s) where convicted

Date of Arrest

Date of Conviction

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