Page _____ of _____ Approved by the Coalition for Court Access
CCA-XP-0220-7009
www.indianalegalhelp.org
FACTS PERTAINING TO EXPUNGEMENT MATTER ________:
CONVICTION FOR A ________________ FELONY THAT DID NOT RESULT IN BODILY INJURY
1. Petitioner was arrested in _______________________ County on __________________ by
_________________________ employed by the law enforcement agency known as _____________________________
under law enforcement agency case number _________________________;
2. Petitioner was convicted on the following charges on _____________________________, under Cause Number
________________________________ in __________________ _________________ Court, Criminal Division,
Room__________.
3. Petitioner is not a person who is prohibited from seeking this remedy under the provisions of I.C. §35-38-9-3(b).
4. Elapsed time:
☐ Eight (8) years have passed between the date of Petitioner’s conviction and the filing of this Petition.
☐ Fewer than eight (8) years have passed between the date of Petitioner’s conviction and the filing of this Petition,
but the ____________________ County Prosecuting Attorney has provided written consent for a shorter elapsed
time period (see Exhibit _____ attached, letter of consent from __________________________ County
Prosecutor).
5. Criminal activity within the previous eight (8) years:
☐ Petitioner affirms that to the best of their knowledge, they have not committed another crime in any jurisdiction
within the previous eight (8) years.
☐ Petitioner affirms that, to the best of their knowledge, they have not committed another crime in any jurisdiction
within the shorter elapsed time period to which the prosecuting attorney has agreed.
6. Petitioner has:
☐ Paid all fines, fees, and court costs, and no restitution obligation was imposed as part of their sentence
☐ Satisfied their restitution obligation of $_____________________ imposed as part of their sentence.
☐ Been found indigent as to all outstanding fines, costs, and fees ordered as part of their sentence.
7. Appellate activity:
☐ The case that Petitioner is requesting be sealed has not been appealed.
☐ The case that Petition is requesting be sealed was appealed on ______________________ under the following
appellate cause number _____________________________.
8. Related MC cause numbers:
☐ Court records stored under the following MC case/cause numbers constitute records of the sentencing court or
juvenile court for the purposes of this order:
__________________________________________________________________________________________
__________________________________________________________________________________________
