Pursuant to A.C.A. § 16-90-905, this Petition to Seal form has been adopted and provided by ACIC. Arkansas law mandates
the use of this form by all petitioners and by all Circuit and District Courts in the state of Arkansas.
In the Court of , Arkansas
Division
Stat e of Arkansas
VS.
(first, middle and last name)
Case No.
Petition to Seal
(Part 1 of 2)
Comes the Defendant and for his/her petition to seal the record states:
(Please complete the appropriate section: A or B)
Section A
1. Defendant was arrested on the day of , and charged with the offense(s) of
A.C.A. § ; the defendant was found guilty of
A.C.A. §
A.C.A. §
, on the day
of and received a sentence of
2. The defendant was sentenced under the provisions of A.C.A. § , which provides for the sealing of a
Defendant's record.
3. Defendant has satisfactorily complied with the conditions and orders of this Court.
4. Defendant has been rehabilitated.
.
Section B
1. Defendant was arrested on the day of , and charged with the offense(s) of
.
.
2. Date of Final Disposition .
Nolle Prossed
Dismissed
Acquitted at Trial
Case Not Filed
Transferred to Juvenile Court
3. Under authority of A.C.A. § 16-90-906, which provides for the sealing of a defendants record, that the
Petition to seal the record of the offense(s) should be granted.
The following information is required for proper identification of the defendant in the state and national record systems:
Race
Sex
DOB
Arrest Tracking No.
SID No.
FBI No.
ACIC Petition-Seal.Doc 06/23/06
(if Known)
(if Known)
The following information is required for proper identification of the defendant in the state and national record systems:
Race
Sex
DOB
Arrest Tracking No.
SID No.
FBI No.
(if Known)
(if Known)
ACIC Petition1-Seal.Doc 06/23/06
Petition to Seal
(Part 2 of 2)
Acknowledgement and Verification:
I. The defendant, hereby verify, under oath, pursuant to A.C.A. §16-90-905(a)(3), that I:
Have pending felony charges in any state or federal court. The status of the charge(s):
(Charge) (Court)
Do not have pending felony charges in any state or federal court..
The requesting party, known by me to be the person identified, did appear before me this
day of
(Signature of Defendant)
(Signature of Notary Public)
(County) (Expiration of Commission)
(SEAL)
The above information is true and correct to the best of my knowledge.
Dated this
day of
(Signature of Attorney for Defendant or Defendant)
(Type or print name of the above)
Certificate of Service
I, , do hereby certify that a true and correct copy of the foregoing Petition has been provided
to the Prosecuting Attorney (for the county in which the petition is filed) and the arresting agency by U.S. Mail, postage pre-paid, or
hand-delivered this
day of
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