Application For Certificate Of Eligibility (Adult)

APPLICATION INSTRUCTIONS FOR CERTIFICATE OF ELIGIBILTY Enclosed is an application for a Certificate of Eligibility to expunge a record of arrest, traffic, detention, investigation or conviction from the State of Utah, Department of Public Safety, Bureau of Criminal Identification. Please complete all of the steps described below. Failure to properly complete one of the steps may cause a delay in processing your application. 1. Fill out the top portion of the application. List all of your previous names including married and maiden names. Be sure to read and sign the application. 2. If you would like your traffic offenses considered in the review of your eligibility for expungement, please check the box designated for "traffic" on the Application for Certificate of Eligibility. Traffic offenses listed under Utah Code Ann. §77-40-102(40) are not included on your Utah Criminal History. If your traffic offenses are approved for a Certificate of Eligibility, there is a $56.00 fee charged for each case that resulted in a conviction, bail forfeiture, plea in abeyance or diversion agreement. Please note that there will be additional fees charged by the court when you file the Certificate of Eligibility with the Petition for Expungement at the court. If the court issues an Order of Expungement, the traffic offense will be removed from court and police records only. Traffic offenses will not be removed from your Utah Driver License record. 3. Take the application to a law enforcement agency such as your city police department or county sheriff's office. Request that they print the four fingers of your right hand on the space provided. Make sure the law enforcement official who takes your fingerprints fills out the portion of the application labeled "OFFICIAL TAKING PRINTS." Valid government-issued photo ID must be provided; for example, passport, state ID card, consulate ID card, or driver license. "Utah Driving Privilege Cards" WILL NOT be accepted by BCI as valid ID. Utah Driving Privilege Cards state on them that they are not to be used as ID. NOTE: The fingerprints may be taken at our office, Bureau of Criminal Identification, 3888 West 5400 South, Taylorsville, Utah. 4. The application fee is $50.00. Select a method of payment by making a check mark in the appropriate box. Checks and money orders must be made payable to "Utah Bureau of Criminal Identification." To pay by credit card (Visa or MasterCard), please fill out the requested information on the application. Credit card numbers must include: the signature of the cardholder, the three-digit control number located on the back of the card, the expiration date, and the zip code of card billing address. Cash is accepted only when applying in person. DO NOT SEND CASH IN THE MAIL. 5. Your eligibility letter will be mailed to the mailing address indicated on the application form. If the information needs to be sent to a third party, the third party release form must be filled out and submitted along with your application. 6. Mail the application, fee and release form (if applicable) to: UTAH BUREAU OF CRIMINAL IDENTIFICATION 3888 West 5400 South Taylorsville, Utah 84129 7. If you were acquitted of your charges, you must mark the box on the application form in order for the bureau to expedite your application. You must include documentation to indicate the charges were acquitted. For expungement criteria or any other questions, please go to our website at http://publicsafety.utah.gov/bci/ The Bureau of Criminal Identification does not expunge Juvenile Court records. Any request to expunge Juvenile Court records must be made directly to the Juvenile Court. American LegalNet, Inc. www.FormsWorkFlow.com E NAME: APPLICATION FOR CERTIFICATE OF ELIGIBILITY Utah Department of Public Safety · Bureau of Criminal Identification 3888 West 5400 South, Taylorsville, Utah 84129 WHEN FILLING OUT THIS APPLICATION TYPE OR PRINT IN BLACK INK. Your application will not be processed unless all sections of this form are filled out completely and accompanied by a $50.00 application fee. DATE OF BIRTH (Last Name) (First Name) (Middle Name) PREVIOUSLY USED NAME(S) (Maiden, AKA, etc.) MAILING ADDRESS: (Street/Box number) (City) (State) (Zip) SOCIAL SECURITY:______________________ DRIVER LICENSE # AND STATE: _______________________/___________ HOME PHONE NUMBER: __________________ DAYTIME PHONE NUMBER: _____________________ CHECK BOX IF TRAFFIC EXPUNGEMENT IS WANTED. ADDITIONAL FEES WILL APPLY AND CHARGES WILL ONLY BE DELETED FROM COURT RECORDS, NOT FROM DRIVER LICENSE FILES CHECK BOX IF ACQUITTAL- DOCUMENTION MUST BE PROVIDED FOR EXPEDITED PROCESSSING Pursuant to Utah Code Ann. § 77-40-106(1)(b), a petitioner who intentionally or knowingly provides false or misleading information to the bureau when applying for a certificate of eligibility is guilty of a class B misdemeanor and subject to prosecution under Section 76-8-504.6. A certification of eligibility or an application for expungement may be denied if the petitioner provides false information. I _____________________________, declare under criminal penalty of the State of Utah that the foregoing is true and correct. (Name of Petitioner) ______________________________________ (signature) Executed on: ___________________________ (Date) METHOD OF PAYMENT (Only to be filled out if application is mailed in. Check appropriate box for payment) $50.00 FEE Check, Money Order or Cashier's Check (Payable to "Utah Bureau of Criminal Identification" in the amount of $50.00) Credit Card Visa OR Master Card Credit Card payment must include 3-digit control number found on the back of the credit card. There is a $20.00 service charge for any returned check. Credit Card Number * 3 digit control # Expiration Date PRINT NAME as it appears on the card: Cardholder signature: Zip code: __________________ Date: FINGERPRINT INSTRUCTIONS: (OFFICIAL TAKING PRINTS) Confirm identity of applicant with identification that shows photo, signature and date of birth. Confirm ID with the information above, then list the type of government issued ID used and the ID number in the space provided below. Fingerprint the four fingers of the applicant's right hand simultaneously in the box located in the lower right portion of this form. OFFICIAL TAKING PRINTS Type of identification used: Utah Driving Privilege Cards are not valid ID and will not be accepted Identification number: Name on ID: Fingerprints taken by: _______________ (Print Name) A