Form Ex-1 - Order For The Expungement Of Criminal Offender Record printable pdf download

(FOR TBI USE ONLY) State Identification Number: ______________________________

(FOR TBI USE ONLY) FBI Identification Number: ______________________________

ORDER FOR THE EXPUNGEMENT OF CRIMINAL OFFENDER RECORD (PLEASE PRINT OR TYPE)

State of Tennessee vs _______________________________________________ Circuit Docket Number_______________________

Date Original Case was filed in Clerk’s Office___________________ General Sessions Docket Number_______________________

In the ____________________Court of __________________________ County, Tennessee at _______________________________

On the Motion or Petition of ______________________________________________________

Defendant/Arrest Information:

_________________________________________________________________________

_____

____

___________

Defendant (name used at time of arrest)

Race

Sex

Date of Birth

________________________________________________________________

_____________ __________________

Arresting Agency

OCA#

Date of Arrest

___________________________________________________________________

________________________________

Charge 1(As shown on arrest fingerprint card)

SSN#

________________________________________________________________________________________________________

Charge 2(As shown on arrest fingerprint card)

________________________________________________________________________________________________________

Charge 3(As shown on arrest fingerprint card)

Disposition Information:

________________________________________________________________________________________________________

Final Charge 1

________________________________________________________________________________________________________

Final Charge 2

________________________________________________________________________________________________________

Final Charge 3

________________________________________________________________________________________________________

Final Disposition

________________________________________________________________________________________________________

Diversion Date (if applicable)

The defendant named above is entitled to have all PUBLIC RECORDS relating to the offenses listed above expunged according to the Tennessee Code

Annotated provision marked below:

Provision relating to Adults:

Provisions relating to Juveniles:

___Charge has been dismissed (T.C.A. § 40-32-101)

___Petition alleging delinquency not filed (T.C.A. § 37-1-155)

___No true bill returned by Grand Jury (T.C.A. § 40-32-101)

___Proceedings dismissed after petition is filed or the case transferred to Juvenile

___Verdict of not guilty returned by jury (T.C.A. § 40-32-101

Court as provided in T.C.A. § 37-1-109 (T.C.A. § 37-1-155)

___Conviction which has by appeal been reversed (T.C.A. § 40-32-101)

___Adjudicated not to be a delinquent child (T.C.A. § 37-1-155)

___Nolle Prosequi entered in case (T.C.A. § 40-32-101)

___Child has reached eighteen (18) years of age and there is no record that he

___Successful completion of all probation provisions and proceedings

committed a criminal offense after reaching sixteen (16) years of age, unless

against defendant have been discharged by the court

such fingerprints were obtained on alleged charge which if committed by an

(T.C.A. § 40-35-313)

adult would be a felony (T.C.A. § 37-1-155)

___Suspension of prosecution pursuant to T.C.A. § 40-15-105

___Passage of six (6) months from date of liquor law violations defined by

T.C.A. § 57-3-412(a)(3)(c) or T.C.A. § 57-5-301(e)(3)

It is ordered that all PUBLIC RECORDS relating to such offense above referenced be expunged and immediately destroyed upon payment of all costs to

clerk and that no evidence of such records pertaining to such offense be retained by any municipal, county, or state agency, except non-public confidential information

retained in accordance with T.C.A. § 10-7-504 and T.C.A. § 38-6-118.

APPROVED FOR ENTRY

________________________________________________

Entered this ______________ day of _______________, _______

Defendant/Attorney for Defendant

________________________________________________

__________________________________________________________

District Attorney General

Judge

Form EX-1 (Rev. 2003)

Form Ex-1 - Order For The Expungement Of Criminal Offender Record

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