Form 2015 Exp 8-1 (L) - Order Of Expungement Of Arrest/conviction Record Page 3

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THUS ORDERED AND SIGNED this ________ day of _____________________, 20 ____
at _________________________, Louisiana.
___________________________________________
JUDGE
___________________________________________
Print Name
PLEASE SERVE THE FOLLOWING:
1. District Attorney: ____________________________________________________________________
(Name and Address)
2. Louisiana Bureau of Criminal Identification and Information: Louisiana State Police, Superintendent
of Records, 7919 Independence Blvd., Baton Rouge, LA 70806
3. Arresting Agency:____________________________________________________________________
(Name and Address)
4. Sheriff: ____________________________________________________________________________
(Name and Address)
5. Attorney for Defendant (or defendant):___________________________________________________
__________________________________________________
(Name and Address)
6. Clerk of Court: ______________________________________________________________________
(Name and Address)
CERTIFICATE OF SERVICE
Pursuant to LA CCrP Article 979, I hereby certify that I have served the foregoing
Order of Expungement to the named entities as listed above on this __________day of
_______________________, 20________, by:
Placing in U.S. Mail
Electronic Transmission
____________________________________
Deputy Clerk of Court
Parish of ____________________________
FORM 2015 EXP 8‐3 (L) 

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