PTSR

Petitioner Name (WITH AKA's)

Petitioner Address

City/State/Zip

Phone Number (include area code)

IN PROPER PERSON

JUSTICE COURT

CLARK COUNTY, NEVADA

In the Matter of the Application of Petitioner Name (WITH AKA's), SCOPE ID#: SCOPE ID number DOB: Date of Birth Ex: 01/01/1980 Last Four of SS#: Last Four of SS# For an Order to Seal Records	CASE NO: DEPT NO:

PETITION TO SEAL RECORDS

COMES NOW Petitioner Name (WITH AKA's), Petitioner, in proper person, pursuant to the provisions of NRS 179.245 and/or 179.255, and respectfully represents the following:

That the Petitioner has been arrested as follows:

Date of Arrest:	First arrest date

Arresting Agency:	Arresting Agency Ex: LVMPD, HPD etc

Charge:	Charge(s) for first arrest

Case Number:	Case Number

Final Disposition Date:	Date of Disposition

Final Disposition:	Disposition 1st arrest

Date of Arrest:	2nd arrest date

Arresting Agency:	Arresting Agency Ex: LVMPD, HPD etc

Charge:	Charge(s) for second arrest

Case Number:	Case Number

Final Disposition Date:	Date of Disposition

Final Disposition:	Disposition 2nd arrest

Date of Arrest:	3rd arrest date

Arresting Agency:	Arresting Agency Ex: LVMPD, HPD etc

Charge:	Charge(s) for 3rd arrest

Case Number:	Case Number 3

Final Disposition Date:	Date of Disposition

Final Disposition:	Disposition 3rd arrest

Date of Arrest:	4th arrest date

Arresting Agency:	Arresting Agency Ex: LVMPD, HPD etc

Charge:	Charge(s) for fourth arrest

Case Number:	Case Number 4

Final Disposition Date:	Date of Disposition

Final Disposition:	Disposition 4th arrest

Date of Arrest:	5th arrest date

Arresting Agency:	Arresting Agency Ex: LVMPD, HPD etc

Charge:	Charge(s) for fifth arrest

Case Number:	Case Number 5

Final Disposition Date:	Date of Disposition

Final Disposition:	Disposition 5th arrest

Date of Arrest:	6th arrest date

Arresting Agency:	Arresting Agency Ex: LVMPD, HPD etc

Charge:	Charge(s) for sixth arrest

Case Number:	Case Number 6

Final Disposition Date:	Date of Disposition

Final Disposition:	Disposition 6th arrest

That the statutory time periods have been fulfilled and that, in the period prescribed for any convictions, the Petitioner has not been arrested, except for minor moving or standing traffic violations, and that further action will not be brought concerning any arrests resulting in dismissal or acquittal.

WHEREFORE, Petitioner waives a hearing in this matter and prays for an Order sealing all records listed above, which are presently in the custody of this Court, of another court in the State of Nevada or of a public or private agency, company or official of the State of Nevada, including but not limited to:

List of Agencies to Seal Records:

Agency 1 (Name and address)

Agency 2 (Name and address)

Agency 3 (Name and address)

Agency 4 (Name and address)

Agency 5 (Name and address)

Agency 6 (Name and address)

Agency 7 (Name and address)

Agency 8 (Name and address)

DATED this _____ day of ___________________, 20____.

Petitioner Name

AFFIDAVIT

(NRS 15.010)

STATE OF NEVADA	)

) ss.

COUNTY OF CLARK	)

I would like the Court to be aware of the following facts that should reflect my commitment to live as a law abiding citizen.

List of reasons why request for sealing records should be granted

Under penalty of perjury, I declare that I am the Petitioner in the above entitled matter; I have read the foregoing Petition to Seal Records and know the contents thereof; that the same is true of my own knowledge except as to those matters therein stated on information and belief, and as to those matters I believe them to be true.

Executed on this _____ day of ___________________, 20____.

Petitioner Name

DECL

Petitioner Name (WITH AKA's)

Petitioner Address

City/State/Zip

Phone Number (include area code)

IN PROPER PERSON

JUSTICE COURT

CLARK COUNTY, NEVADA

In the Matter of the Application of Petitioner Name (WITH AKA's), SCOPE ID#: SCOPE ID number DOB: Date of Birth Ex: 01/01/1980 Last Four of SSN: Last Four of SS# For an Order to Seal Records	CASE NO: DEPT NO:

DECLARATION

(NRS 15.010)

I, Petitioner Name (WITH AKA's), declare:

I am the Petitioner in the above-entitled matter; I have read the foregoing Petition to Seal Records and know the contents thereof; that the same is true of my own knowledge except as to those matters therein stated on information and belief, and as to those matters I believe them to be true,

I declare under penalty of perjury under the law of the State of Nevada that the foregoing is true and correct.

DATED this _____ day of ______________ 20____.

Submitted by:

_________________________________________

Petitioner Name (WITH AKA's)

Petitioner Address

City/State/Zip

Phone Number (include area code)

IN PROPER PERSON
ORDR

Petitioner Name (WITH AKA's)

Petitioner Address

City/State/Zip

Phone Number (include area code)

IN PROPER PERSON

JUSTICE COURT

CLARK COUNTY, NEVADA

In the Matter of the Application of Petitioner Name (WITH AKA's), SCOPE ID#: SCOPE ID number DOB: Date of Birth Ex: 01/01/1980 Last Four of SSN: Last Four of SS# For an Order to Seal Records	CASE NO: DEPT NO:

ORDER TO SEAL RECORDS

Pursuant to the Petition of Petitioner Name (WITH AKA's), Petitioner, in proper person, and Steven B. Wolfson, District Attorney for Clark County, Nevada, having stipulated below, the Court finding that the statutory requirements of NRS 179.245 and/ or 179.255, are satisfied, and good cause appearing, therefore

IT IS HEREBY ORDERED that the following record(s) of arrest(s) be sealed:

That the Petitioner has been arrested as follows:

Date of Arrest:	First arrest date

Arresting Agency:	Arresting Agency Ex: LVMPD, HPD etc

Charge:	Charge(s) for first arrest

Case Number:	Case Number

Final Disposition Date:	Date of Disposition

Final Disposition:	Disposition 1st arrest

Date of Arrest:	2nd arrest date

Arresting Agency:	Arresting Agency Ex: LVMPD, HPD etc

Charge:	Charge(s) for second arrest

Case Number:	Case Number

Final Disposition Date:	Date of Disposition

Final Disposition:	Disposition 2nd arrest

Date of Arrest:	3rd arrest date

Arresting Agency:	Arresting Agency Ex: LVMPD, HPD etc

Charge:	Charge(s) for 3rd arrest

Case Number:	Case Number 3

Final Disposition Date:	Date of Disposition

Final Disposition:	Disposition 3rd arrest

Date of Arrest:	4th arrest date

Arresting Agency:	Arresting Agency Ex: LVMPD, HPD etc

Charge:	Charge(s) for fourth arrest

Case Number:	Case Number 4

Final Disposition Date:	Date of Disposition

Final Disposition:	Disposition 4th arrest

Date of Arrest:	5th arrest date

Arresting Agency:	Arresting Agency Ex: LVMPD, HPD etc

Charge:	Charge(s) for fifth arrest

Case Number:	Case Number 5

Final Disposition Date:	Date of Disposition

Final Disposition:	Disposition 5th arrest

Date of Arrest:	6th arrest date

Arresting Agency:	Arresting Agency Ex: LVMPD, HPD etc

Charge:	Charge(s) for sixth arrest

Case Number:	Case Number 6

Final Disposition Date:	Date of Disposition

Final Disposition:	Disposition 6th arrest

A copy of this Order shall be sent by Petitioner to each public or private agency, company or official of the State of Nevada, including but not limited to:

List of Agencies to Seal Records:

Agency 1 (Name and address)

Agency 2 (Name and address)

Agency 3 (Name and address)

Agency 4 (Name and address)

Agency 5 (Name and address)

Agency 6 (Name and address)

Agency 7 (Name and address)

Agency 8 (Name and address)

As named in the Petition, and such organization or individual shall seal the records in its custody which relate to the matters contained in this Order, shall advise the Court of its compliance and shall then seal the order.

All proceedings recounted in the sealed records are deemed never to have occurred, and the person to whom this order pertains may properly answer accordingly to any inquiry, including without limitation an inquiry relating to an application for employment, concerning the sealed arrest, conviction, dismissal or acquittal and the events and proceedings relating to the arrest, conviction, dismissal or acquittal.

ORDERED on this _____ day of ___________________, 20____.

COURT JUDGE

Submitted by:

Petitioner Name (WITH AKA's)

Petitioner Address

City/State/Zip

Phone Number (include area code)

IN PROPER PERSON

The District Attorney has reviewed the applicable criminal history and agrees that the record is statutorily eligible for sealing. The petition and order have not been reviewed for completeness or accuracy. The decision to order the sealing of a record remains solely within the discretion of the court. See NRS 179, et seq.

STEVEN B. WOLFSON

DISTRICT ATTORNEY

By:

NV Bar Number: __________________