Petition For Expungement Page 3
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4CC-1473 – PETITION FOR EXPUNGEMENT FILED IN A CIRCUIT COURT –
PAGE: 3
ACQUITTAL/DISMISSAL
DATA ELEMENTS
1. Court case number.
17. Signature of petitioner or attorney for
petitioner. Check applicable box under the
line.
2. Court name.
18. Print name of individual signing the petition.
3. Street address of court.
19. Insert address and telephone number of
4. Name of petitioner.
individual signing the petition and check
applicable box under the line.
5. Check the applicable box.
20. Clerk of court or deputy clerk insert hearing
6. Insert date of birth of petitioner.
date and time.
7. Insert full name of petitioner at the time
21. Signature of clerk or deputy clerk.
of arrest.
22. Insert date of clerk or deputy clerk signature.
8. List criminal charge(s) petitioner seeks to
have expunged.
23. Clerk of court or deputy clerk check box.
9. Check box if a copy of the warrant or
24. Petitioner may use the check boxes to
indictment is attached.
indicate the steps completed.
10. Insert court case number(s) associated
with the charges sought be expunged.
11. Insert date of arrest for the charge(s)
sought to be expunged.
12. Insert name of arresting agency.
13. Check applicable box(es) if the
information indicated is not available and
state the reason the information is not
available on the blank lines.
14. Insert date of final disposition of
charge(s) sought to be expunged.
15. Insert name of court disposing of
charge(s).
16. Insert date petition is signed.
•
Office of the Executive Secretary
Supreme Court of Virginia
Rev 7/07
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