STATE OF MICHIGAN

JUDICIAL DISTRICT
JUDICIAL CIRCUIT
 

ORDER ON APPLICATION BY 
HUMAN TRAFFICKING VICTIM
TO SET ASIDE CONVICTION(S)

Court address

CASE NO. and JUDGE

 This application includes multiple case      

      numbers as listed in item 1.

Court telephone no.

ORI
MI-

Police Report No.

THE PEOPLE OF

 The State of Michigan

Defendant’s name, address, and telephone no.

v

CTN/TCN

SID

DOB

Instructions:  An order may not be entered until receipt of the report of the Michigan State Police.  Copies of the order must be sent to the
Michigan State Police and the prosecuting official. See page 3 for a list of offenses in MCL 780.621c that may not be set aside.

This order should not be used with applications to set aside a conviction under MCL 780.621(1), or misdemeanor marihuana offenses 
under MCL 780.621e. 

1. An application to set aside the following conviction(s) was filed on 

 . 

Date

CRIME

CHARGE CODE(S)
MCL citation/PACC Code

DATE OF 
CONVICTION

CASE NUMBER

THE COURT FINDS:

2. The Michigan State Police has reported the required information from its records to the court.

3. The applicant 

 

 has  

 

 has not 

  been convicted of more than three felonies.

4. The applicant has had  
 no 
  MCL 780.621 during their lifetime.

 

 

 
 No.

  

  convictions for an assualtive crime set aside under 

5. There 

 

 are 

 

 are not 

  criminal charges pending against the applicant.  

 6. The applicant was convicted of a violation under MCL 750.448, MCL 750.449, MCL 750.450, or a local 
    ordinance substantially corresponding to one of those statutes and has proven by a preponderance of the evidence 
    that the following conviction(s) listed in item 1 is/are the direct result of his or her being a victim of human trafficking: 

 
 

a.

b.

c.

d.

 
 

 

 

 

   

   

Approved, SCAOForm MC 228b, Rev. 3/21MCL 780.621, MCL 780.621b, MCL 780.621d, MCL 780.622, MCL 780.623Page 1 of 3Distribute form to:CourtState PoliceArresting agencyProsecuting officialDefendantAttorney GeneralOrder on Application by Human Trafficking Victim to Set Aside Conviction(s)  
Page 2 of 3

(3/21) 

Case No. 
 

 7. The applicant has not proven by a preponderance of the evidence that the following conviction(s) listed in item 1 

    is/are the direct result of his or her being a victim of human trafficking: 

  

 8. The following convictions listed in item 1 occurred within 24 hours and arose from the same transaction pursuant to 
    MCL 780.621b: 

  

 9. An opportunity has been given to the Attorney General and prosecuting official to contest the application.

 10.  Circumstances and behavior of the applicant from the date of the applicant’s convictions(s) to the filing of the 
      application warrant setting aside the conviction(s), and it is consistent with the public welfare.

IT IS ORDERED:  

 11.  The application is denied as to the following conviction(s) listed in item 1:  

  
 
 

      Applicant may file another application to have the conviction(s) above set aside  
     
     

 three years after the date of this order.  
 earlier than three years after the date of this order, but no sooner than 

  OR

 .

 12.  The application is granted as to the following conviction(s) listed in item 1: 

   

Date

   

      The following convictions listed in item 1 are considered one conviction pursuant to MCL 780.621b:  
     
     

 

      Under MCL 780.623 the Michigan State Police shall maintain a nonpublic record of the order setting aside 
      conviction and of the arrest, fingerprints, conviction, and sentence in this case. If the court or arresting agency 
      maintains a record of the arrest, biometric data, conviction or sentence, that record shall be nonpublic and not 
      used for any purpose unless authorized by law.

   

  

 

     

  

     

  

 

 

 

 

 

 

 
 
 

 
 
 
 

 

                                                                                           Judge signature and date

NOTE TO APPLICANT: An order setting aside a conviction does not relieve any obligation by the applicant to pay restitution 
owed to the victim of a crime nor does it affect the jurisdiction of the convicting court or the authority of any court order with 
regard to enforcing an order for restitution. The applicant is not entitled to the return of any fine, costs, or other money paid 
as a consequence of a conviction that is set aside.

NOTE TO  COURT:    Under  MCL  769.16a  the  clerk  of  the  court  shall  advise  the  Michigan  State  Police  Criminal  Justice 
Information Center of the disposition. 

Order on Application by Human Trafficking Victim to Set Aside Conviction(s)  
Page 3 of 3

(3/21) 

Case No. 
 

Convictions that May Not Be Set Aside:

MCL 780.621c prohibits the court from setting aside certain convictions as follows:
 
 
 

 
(a)  A felony for which the maximum punishment is life imprisonment or an attempt to commit a felony for which the maximum 
      punishment is life imprisonment. 

 
 
 

 
 

 
 
 
 
 
 

 

 
 

(b)  A violation or attempted violation of section 136b(3), 136d(1)(b) or (c), 145c, 145d, 520c, 520d, or 520g of   
      the Michigan penal code, 1931 PA 328, MCL 750.136b, 750.136d, 750.145c, 750.145d, 750.520c, 750.520d, and  
      750.520g.

(c)  A violation or attempted violation of section 520e of the Michigan penal code, 1931 PA 328, MCL 750.520e, if the  
      conviction occurred on or after January 12, 2015.

(d)  The following traffic offenses:
      (i) A conviction for operating while intoxicated by any person.
      (ii) Any traffice offense committed by an individual with an indorsement on his or her operator’s or chauffeur’s license 
          to operate a commercial motor vehicle that was committed while the individual was operating the commercial 
          motor vehicle or was in another manner a commercial motor vehicle violation.
      (iii) Any traffic offense that causes injury or death.

(e)  A felony conviction for domestic violence, if the person has a previous misdemeanor conviction for domestic violence.

(f)   A violation of former section 462i or 462j or chapter LXVIIA or chapter LXXXIII-A of the Michigan penal code, 
      1931 PA 328, MCL 750.462a to 750.462h and 750.543a to 750.543z.