Application For Certification Of Eligibility - Florida Department Of Law Enforcement
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6FLORIDA DEPARTMENT OF LAW ENFORCEMENT
APPLICATION FOR CERTIFICATION OF ELIGIBILITY
PLEASE TYPE OR PRINT ALL INFORMATION
Last Name
First Name
Middle Name
Aliases: Maiden: Divorce
Residence Phone
Business Phone
(
)
(
)
Date of Birth (DOB)
Race
Sex
Social Security No.
MONTH
DAY
YEAR
Mailing Address
City
State
Zip
Permanent Address
City
State
Zip
Arresting Agency
Date(s) of Arrest
Florida Drivers License No.
Select One: _____Expunge
_____Seal
NOTE: For Expunction applications, the State Attorney or Statewide Prosecutor must complete Section B.
Charge(s)
NOTARY
(PLEASE STAMP WITH SEAL)
1. __________________________________________
Sworn to and subscribed before me
2. __________________________________________
This ______ Day of _______________, 20____________
3. __________________________________________
______________________________________________
4. __________________________________________
(Signature of Notary Public)
________________________________________
I hereby certify that the information contained herein is
(Print, Type, or Stamp Commissioned Name of Notary
true and correct to the best of my knowledge.
or Deputy Clerk of the Court)
Personally Known ____ or Produced Identification _____
___________________________________________
Signature
Date
Type of Identification Produced: ____________________
State Attorney/Statewide Prosecutor
County
Circuit
Reviewing Officer
Charge(s) Description
Statute Violation
Case Number
Action
FOR EXPUNCTION
1. ___________________________________
___________________
_________________
_________________
2. ___________________________________
___________________
_________________
_________________
3. ___________________________________
___________________
_________________
_________________
APPLICATIONS ONLY
4. ___________________________________
___________________
_________________
_________________
The above-referenced case is not eligible to be expunged because:
If one of the paragraphs below is checked, my signature below indicates that, based on the
disposition of all charges related to the above-referenced case, that case is eligible to be
One or more of the charges (acts) related to the arrest or alleged criminal activity to which the
expunged, if the applicant is otherwise eligible to have his or her record expunged under law. My
application for certificate of eligibility to expunge pertains resulted in an adjudication of guilt or
signature does not imply that the applicant has satisfied all other statutory eligibility criteria, or
of delinquency;
that this Office would not oppose a petition to expunge the above-referenced case. By checking
paragraph 1, 2, or 3, I certify that the above-referenced case is presently eligible to be expunged,
OR, BECAUSE OF ONE OR MORE OF THE FOLLOWING REASONS:
assuming that the applicant is otherwise eligible, because:
The record of the arrest or alleged criminal activity to which the application for certificate of
1. An indictment, information, or other charging document was not filed or issued in the
eligibility to expunge pertains has not been sealed for at least 10 years;
case; OR
One or more of the charges for which an adjudication of guilt or of delinquency was withheld
2. An indictment, information, or other charging document, if filed or issued in the case,
relate to a to a violation of s. 393.135, s. 394.4593, s. 787.025, chapter 794, s. 796.03, s.
was dismissed or nolle prosequi by the state attorney or statewide prosecutor, or was
800.04, s. 810.14 s. 817.034, s. 825.1025, s. 827-071, chapter 839, s. 847.0133, s. 847.0135,
dismissed by a court of competent jurisdiction; OR
s. 847.0145, s. 893.135, s. 916.1075, a violation enumerated in s. 907.041, or any violation
specified as a predicate offense for registration as a sexual predator pursuant to s. 775.21,
3. (a) None of the charges (acts) related to the arrest or alleged criminal activity to which
without regard to whether that offense alone is sufficient to require such registration, or for
the application for certificate of eligibility to expunge pertains resulted in an adjudication of
registration as a sexual offender pursuant to s. 943.0435;
guilt or of delinquency; AND
(b) The record of the arrest or alleged criminal activity to which the application for
certificate of eligibility to expunge pertains has been sealed for at least 10 years; AND
Records available to this Office disclose some other ground of statutory ineligibility (e.g.,
(c) None of the charges (if any) for which adjudication of guilt or of delinquency was
adjudication of guilt in a different case; previous expunction or sealing).
withheld relates to a violation of s. 393.135, s. 394.4593, s. 787.025, chapter 794, s.
796.03, s. 800.04, s. 810.14, s. 817.034, s. 825.1025, s. 827.071 chapter 839, s.
847.0133, s. 847.0135. s. 847.0145, s. 893.135, s. 916.1075, a violation enumerated in s.
907.041, or any violation specified as a predicate offense for registration as a sexual
predator pursuant to s. 775.21, without regard to whether that offense alone is sufficient
to require such registration, or for registration as a sexual offender pursuant to s.
943.0435.
__________________________________________________
____________________________________________________
Signature
Title(Prosecuting Authority)
Date
Signature
Title(Prosecuting Authority)
Date
Acct/Budget
Expunge/Seal Section
Expunge/Seal Section
Date Received __________________
I.D.# ________________ORI _______________
Date Received __________________
Check _________________________
Certification Status
Approved
Denied
Date Entered ___________________
Processed By ___________-_______
Seal
Date Mailed ____________________
Expunge
IMPORTANT: A CERTIFICATE OF ELIGIBILITY IS VALID FOR 12 MONTHS FROM THE DATE OF ISSUANCE. AFTER
THAT TIME, A NEW CERTIFICATE MUST BE APPLIED FOR.
Revised December 2009
Ref. Rules 11C-7.006 and 11C-7.007
FDLE 40-021
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