Application Form For Destruction Of Juvenile Records, Setting Aside Adjudications, And/or Restoration Of Civil Rights - Mohave County

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FOR CLERK USE ONLY
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SUPERIOR COURT OF ARIZONA IN MOHAVE COUNTY
Case Number: ________________________
In the matter of:
APPLICATION FOR DESTRUCTION
OF JUVENILE RECORDS, SETTING
ASIDE ADJUDICATIONS, and/or
RESTORATION OF CIVIL RIGHTS
_________________________________
(Applicant’s Name)
(USING BLACK INK, PRINT IN LARGE CLEAR LETTERS)
____________________________
____________________________
___________________________
Last Name
First Name
Middle Name
___________________________________________
________________________________________
Street Address
Mailing Address (if different)
___________________________________________
________________________________________
City, State, Zip Code
City, State, Zip Code
County of Residence: __________________________
Date of Birth:________________________
Phone Number: ________________________________
(Month / Day / Year)
Message Number:_____________________________ Email:__________________________________
Police Agency to be notified (for Destruction of Records Applicants ONLY) ________________________________
___________________________________________________________________________________________
I apply for the relief indicated and certify under penalty of law that the following is true (as marked):
I request the destruction of juvenile records as designated by my application.
•
I am at least 18 years of age; and
•
I have not been convicted of a felony offense or adjudicated delinquent for an offense listed in A.R.S.
§13-501 subsection A or B or Title 28 Chapter 4; and
•
A criminal charge is not pending against me; and
•
I have successfully completed all terms and conditions of court-ordered probation, or I have received
an absolute discharge from the Arizona department of Juvenile Corrections; and
•
All restitution and monetary assessments have been paid in full, by me and my parents or guardian
OR
•
I am at least 25 years of age; and
•
I have not been convicted of a felony offense; and
•
A criminal charge is not pending against me; and
•
I have successfully completed all terms and conditions of court-ordered probation or I have received an
absolute discharge from the Arizona department of Juvenile Corrections: and
•
All restitution and monetary assessments have been paid in full, by me and my parents or guardian.
1 of 3
8/10/2009

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