AOPC Form Updated Rev 03/09/12
Petition for Expungement Pursuant to Pa.R.Crim.P. 490
AND NOW, the petitioner avers the following and requests that this petition for expungement pursuant to
Pa.R.Crim.P. 490 be granted for the reasons set forth below.
Full Name:
Social Security Number:
List name, address of Judge of the Magisterial District or Philadelphia Municipal Court who accepted the guilty plea or heard the
Magisterial District Court Number:
Philadelphia Municipal Court or Magisterial District Docket Number:
Name of Arresting Agency:
Date of Arrest:
Date on Citation or Complaint:
List name and mailing address of the affiant as shown on the complaint or citation, if available:
Name of Affiant:
List specific charges, as they appear on the charging document, to be expunged and the disposition of each charge (please attach
additional sheet(s) of paper if necessary):
PA Statute
Section Subsection Statute Description Counts Grade Disposition
If the sentence imposed included a fine, costs or restitution, has the amount due been paid? Yes No
List the reason(s) for the expungement (please attach additional sheet(s) of paper if necessary):
I have attached a copy of my Pennsylvania State Police Criminal History which I have obtained within 60 days before filing this
I have not attached a copy of my Pennsylvania State Police Criminal History. State reason(s) below:
When this petition is filed with the Clerk of Courts, the petitioner shall serve a copy upon the attorney for the Commonwealth.
I, the undersigned petitioner, avers that the facts set forth in this petition are true and correct to the best of my
personal knowledge or information and belief, and are made subject to the penalties of unsworn falsification to authorities
under 18 Pa.C.S § 4904.
_________________________________ __________________
Signature of Petitioner Date
In the Court of Common Pleas
County of
Judicial District
Commonwealth of Pennsylvania
Docket No: CP- - - -20
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