Form 2015 Exp 5-1 (L) - Motion For Expungement
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1
2
3City of Bossier City
Number ____________________
STATE OF LOUISIANA
NO. _________________________ DIV ____
Bossier City Court
___________ JUDICIAL DISTRICT COURT
VERSUS
PARISH OF____________________________
Bossier Parish, Louisiana
___________________________________
STATE OF LOUISIANA
MOTION FOR EXPUNGEMENT
NOW INTO COURT comes mover, who provides the court with the following information in connection
with this request:
I.
DEFENDANT INFORMATION
NAME: ____________________________
___________________________
________________________
(Last Name)
(First Name)
(Middle Initial)
DOB: ________/________/__________ (MM/DD/YYYY)
GENDER _______ Female _______Male
SSN (last 4 digits): XXX-XX-________________
RACE: __________________________________
DRIVER LIC.# ____________________________
ARRESTING AGENCY: _______________________________________________________________________
SID# (if available): ____________________________________________________________________________
ARREST NUMBER (ATN):_____________________________________________________________________
AGENCY ITEM NUMBER: ____________________________________________________________________
Mover is entitled to expunge the record of his arrest/conviction pursuant to Louisiana Code of Criminal
Procedure 971 et seq. and states the following in support:
II.
ARREST INFORMATION
1. Mover was arrested on _______/______/_______ (MM/DD/YYYY)
2.
YES
NO
A supplemental sheet with arrests and/or convictions is attached after page 2
of this Motion.
3. Mover was:
YES
NO
Arrested, but it did not result in conviction
YES
NO
Convicted of and seeks to expunge a misdemeanor
YES
NO
Convicted of and seeks to expunge a felony
4. Mover was booked and/or charged with the following offenses: (List each offense booked and charged
separately. Please number each item numerically beginning with Number 1. Attach a supplemental sheet,
if necessary.)
Yes
No
ARRESTS THAT DID NOT RESULT IN CONVICTION
ITEM NO. ______
La. Rev. Stat. Ann.
§ ____________ : ______________
Name of the offense
__________________________________________________
Time expired for prosecution _____/_____/______ (MM/DD/YYYY)
Not prosecuted for any offense arising out of this charge
Pre-trial Diversion Program
DWI Pre-Trial Diversion Program and 5 years have elapsed since the
date of arrest
Charge dismissed
Found not guilty/judgment of acquittal
ITEM NO. ______
La. Rev. Stat. Ann.
§ ____________ : ______________
Name of the offense
__________________________________________________
Time expired for prosecution _____/_____/______ (MM/DD/YYYY)
Not prosecuted for any offense arising out of this charge
Pre-trial Diversion Program
DWI Pre-Trial Diversion Program and 5 years have elapsed since the
date of arrest
Charge dismissed
Found not guilty/judgment of acquittal
FORM 2015 EXP 5‐1 (L)
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