In the matter of 

First and last name of juvenile

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.

THE COURT FINDS:

 1. The Michigan State Police has reported to the court required information from the department’s records.

 2. The applicant has not been adjudicated for more offenses than allowed under MCL 712A.18e(1) and does not have 
    an adult felony conviction.
   
        displayed a single intent and goal.

 The adjudications arose out of a series of acts that were in a continuous time sequence of 12 hours or less and

 
 
 

 3. The adjudication(s) is/are not for a felony for which the maximum punishment is life imprisonment.

 4. It has been at least one year since termination of jurisdiction.

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

 6. Circumstances and behavior of the applicant justify setting aside the adjudication(s), and it is consistent with the 
    public welfare.

 

IT IS ORDERED: (If any item from 1 through 6 is not checked, then item 7 must be checked.)

 7. The application is denied.

 8. The following adjudication(s) in this case is/are set aside: 

 

 
 
 
 
 
 
 

 

     
 .
      Under MCL 712A.18e(13), the Michigan State Police shall maintain a nonpublic record of the order setting aside   
      one or more adjudications and of the arrest, biometric data, adjudication(s), and disposition in this case. If an 
      adjudication is for a nontraffic offense that was reportable to the Secretary of State in accordance with 
      MCL 257.732(22), the driving record shall not be expunged. If the court or arresting agency maintains a record of 
      the arrest, biometric data, adjudication, or disposition, that record shall be nonpublic and not used for any purpose 
      unless authorized by law.

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

Approved, SCAO
Form JC 105, Rev. 4/21
MCL 712A.18e, MCR 3.925(F)
Page 1 of 1

Judge signature and date

Distribute form to:
Court
State Police
Arresting agency
Prosecuting official
Defendant
Attorney General

STATE OF MICHIGANJUDICIAL CIRCUIT - FAMILY DIVISIONCOUNTY ORDER ON APPLICATION TO SET ASIDE ADJUDICATION(S)CASE NO.PETITION NO.JUDGEORIMI-Court addressCourt telephone no.Police Report No.CTN/TCNSIDDOBDate of Offense(s)Charge(s)