IN THE CIRCUIT COURT OF
COUNTY, MISSOURI
Judge or Division:
Case Number:
Court ORI Number:
Petitioner:
vs.
(Date File Stamp)
Defendant(s):
Circuit Court Division
County Sheriff's Dept.
Associate Court Division
Municipal Police Dept
Municipal Court Division
Missouri Highway Patrol Troop
Criminal Records Repository
Prosecutor's Office (include name of county or city)
County
Municipal
Other (include name and address of agency)
Petition for Expungement of Arrest Records
Pursuant to Section 610.122, RSMo, I request that the court issue an order to expunge my record of arrest, for the following cr iminal
case:
I am filing this pe tition in the county where the arrest occurred and I here by swear that I have no pr ior or subsequent misdeme anor or
felony convictions and I did not receive a suspended imposition of sentence (SIS) for the offense for which the arrest was made or for any
offense related to the arrest. I also state that the arrest was based on false information, there is no probable cause at the time of the action
to expunge to believe that I committed the offense and charges will be pursued as a result of the arrest, and no civil action is pending
relating to the arrest or the records sought to be expunged .I am providing my fingerprints on a standard fingerprint card for verification of
my identity.
I have reason to believe the agenci es named above as defendants may possess records subject to expungement.
Full Name
Sex
M
F
Race
Social Security Number
Driver's License Number
Date of Birth
Address at Time of Arrest
Offense Charged
Arrest Citation Number
If criminal charges were filed, date of dismissal or reversal
Date of Arrest
County where Petitioner was arrested
Name of Arresting Agency
(if Arrest Occurred in a Munici pality, also Name Municipality)
Case Number and Division of Court of the Offense
Circuit
Associate
Municipal
Division
#
Not Applicable
I swear the facts stated in the above petition ar e true according to my best knowledge and belief.
Petitioner's Signature/Address
Subscribed and sworn to before me this
day of
,
My commission expires:
Notary Public/Judge/Clerk
OSCA (7-03) CR145
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Chapter 610 RSMo
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