, a disposition hearing was held because I was adjudicated, as a juvenile delinquent, of 

the following offense(s): 

 
  A certified record of the adjudication(s) is attached. 
 
 

 I was not detained for the offense(s). 
 I completed the term of detention for the offense(s) on 

 

 

 . 

 

 No other application has been filed to set aside this/these or any other adjudication(s) in any court. 
 One or more applications were filed to set aside adjudications and the applications are pending or were disposed. 

  OR

    Copies of any applications and orders are attached. 

 

 

3. At least one year has passed since termination of jurisdiction. No criminal charges are pending against me. I have not   
  been adjudicated for more offenses than allowed under MCL 712A.18e(1). I do not have an adult felony conviction.

 4. I am requesting that multiple adjudications be set aside as one offense. These adjudications arose out of a series of 
    acts that were in a continuous time sequence of 12 hours or less and displayed a single intent and goal.

 

 5. I have completed the Michigan Youth ChalleNGe Academy. My certificate of completion is attached to this application.

6. I request that the court issue an order to set aside the above adjudication(s) as provided by law. I consent to the use of 
 

the nonpublic record created by MCL 712A.18e(13) to the extent authorized by MCL 780.623.

Applicant signature

 

                     
                     

 
Subscribed and sworn to before me on 
 

                     

Date

 

Address

City, state, zip  
 
 

 

 

 

 

Telephone no.

 

 

 

 

 

 

 

 

My commission expires on 
 
Notary public, State of Michigan, County of 

                     

 

 

Deputy clerk/Notary public signature

 . 

Name (type or print)
 

 

 . 

 Acting in the County of 

 

 This notarial act was performed using an electronic notarization system or a remote electronic notarization platform.

 . 

 . 
 

 .

1. On 

Date

   

2. 
 
 

In the matter of 

First and last name(s), alias(es)

Approved, SCAO
Form JC 66, Rev. 4/21
MCL 28.241a(b), MCL 712A.18e, MCR 3.925(F)
Page 1 of 2

Distribute form to: 
Court 
Applicant
Prosecuting official
Attorney General
State Police
Return

STATE OF MICHIGANJUDICIAL CIRCUIT - FAMILY DIVISIONCOUNTYAPPLICATION TOSET ASIDE ADJUDICATION(S)CASE NO.PETITION NO.JUDGEORIMI-Court addressCourt telephone no.Police Report No.CTN/TCNSIDApplication to Set Aside Adjudication(s) 
Page 2 of 2

(4/21) 

Case No. 
 

NOTICE OF HEARING

The hearing cannot be held until the court receives the Michigan State Police report required under MCL 712A.18e(5).

TO:  Michigan Attorney General and 

Prosecuting official

A hearing will be held on the above application to set aside adjudication(s) on 

at 

Location

Date and time

 before 

PROOF OF SERVICE

 .

 

I certify that copies of this application, certified record of adjudication(s), and notice of hearing were served on the
                                                                                                                 

 prosecuting official on 

 by first-class mail addressed to the last-known address.

                                                                                                                  

 Attorney General on 

 by first-class mail addressed to the last-known address.

Date

Date

I certify that copies of this application, certified record of adjudication(s), and biometric data were served on the Michigan 
State Police on 

 by first-class mail addressed to the last-known address. 

Date

I declare under the penalties of perjury that this proof of service has been examined by me and that its contents are true to 
the best of my information, knowledge, and belief.

Date

 

Applicant signature

INSTRUCTIONS:
For additional instructions and an online interview that will help you create forms, go to michiganlegalhelp.org.

it to your application.

the time of filing, the clerk of the court will complete the Notice of Hearing.

1. Determine whether you are eligible to apply to have your adjudication set aside according to MCL 712A.18e. You must 
  complete a separate application for each adjudication if you are applying to have more than one adjudication set aside.
2. Find out the exact date of adjudication and the charge from the court. Get a certified copy of the adjudication and attach 
 
3. Swear to the truth of the statements in this application and then sign it in the presence of the court clerk or a notary public.
4. Make four copies of all attachments and this application. Take all copies to the court clerk.
5. Depending on local practice, the clerk of the court may set a hearing date at the time of filing. If a hearing date is set at 
 
6. Go to the local law enforcement agency for biometric data collection. There may be a fee for this.
7. Mail a copy of the application packet and your biometric data to the Michigan State Police by first-class mail to
  Michigan State Police, Criminal Justice Information Center - Criminal History, PO Box 30266, Lansing, Michigan 
  48909.
8. Mail a copy of the application packet to the Attorney General of the State of Michigan by first-class mail to Office of the
  Attorney General, Criminal Appellate Division, PO Box 30217, Lansing, Michigan 48909.
9. Mail a copy of the application packet to the correct prosecuting official where the conviction occurred (county, city, or 
 
  of county prosecutors.
10.  On the remaining copies of the application, fill in the Proof of Service on page 2 of the form. After you fill out and sign 
  the Proof of Service, mail or take one of the remaining application packets with the completed Proof of Service to the   
 
  court. Keep the other copy of the application packet for your records.
 

township) by first-class mail. See www.michiganprosecutor.org/about-us-menu/prosecutor-directory for the addresses