Form 2015 Exp 5-1 (L) - Motion For Expungement Page 2
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3ITEM 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
Yes
No
MISDEMEANOR CONVICTIONS
ITEM NO. ______
La. Rev. Stat. Ann.
§ ____________ : ______________
Name of the offense
__________________________________________________
Conviction set aside/dismissed
_____/______/______
Pursuant to C.Cr.P. Art. 894(B)
(MM/DD/YYYY)
More than 5 years have passed since complete of sentence.
ITEM NO. ______
La. Rev. Stat. Ann.
§ ____________ : ______________
Name of the offense
__________________________________________________
Conviction set aside/dismissed
_____/______/______
Pursuant to C.Cr.P. Art. 894(B)
(MM/DD/YYYY)
More than 5 years have passed since complete of sentence.
Yes
No
FELONY CONVICTIONS
ITEM NO. ______
La. Rev. Stat. Ann.
§ ____________ : ______________
Name of the offense
__________________________________________________
Conviction set aside/dismissed
_____/______/______
Pursuant to C.Cr.P. Art. 893(E)
(MM/DD/YYYY)
More than 5 years have passed since complete of sentence.
ITEM NO. ______
La. Rev. Stat. Ann.
§ ____________ : ______________
Name of the offense
_________________________________________________
Conviction set aside/dismissed
_____/______/______
Pursuant to C.Cr.P. Art. 894(B)
(MM/DD/YYYY)
More than 5 years have passed since complete of sentence.
Yes
No
OPERATING A MOTOR VEHICLE WHILE INTOXICATED CONVICTIONS
Mover has attached the following:
A certified letter of compliance in accordance with C.Cr.P. Art. 984 from the Department of
Public Safety and Corrections, office of motor vehicles that it has received from the clerk of court
a certified copy of the record of the plea, fingerprints of the defendant, and proof of the
requirements set forth in C.Cr.P.Art. 556, which shall include the defendant's date of birth, last
four digits of social security number, and driver's license number
5. Mover has attached to this Motion the following pertinent documents:
Criminal Background Check from the La. State Police/Parish Sheriff dated within the past 30 days
(required).
Bill(s) of Information (if any).
Minute entry showing final disposition of case (if any).
Certification Letter from the District Attorney for fee waiver (if eligible).
Certification Letter from the District Attorney verifying that the applicant has no convictions or
pending applicable criminal charge in the requisite time periods.
Certification Letter from the District Attorney verifying that the charges were refused.
Certification Letter from the District Attorney verifying that the applicant did not participate in a
pretrial diversion program.
A copy of the order waiving the sex offender registration and notification requirements.
FORM 2015 EXP 5‐2 (L)
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