STATE OF MICHIGAN

JUDICIAL DISTRICT
JUDICIAL CIRCUIT
 

Court address

ORDER ON APPLICATION TO 
SET ASIDE CONVICTION(S)

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(3), involving victims of human 
trafficking, or under MCL 780.621e, misdemeanor marihuana offenses. 

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

a.

b.

c.

d.

 
 

 
 

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.

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

 

 

 
 

  

  convictions for an assaultive crime set aside under 

5. There 

 

 are 

 

 are not 

  criminal charges pending against the applicant.  

6. The applicant 
 

 
required under MCL 780.621. 

 has 

 

 has not 

  been convicted of any criminal offense during the applicable time period 

 7. The applicant is requesting that a felony offense punishable by more than 10 years imprisonment be set aside.  
    The applicant 
    MCL 780.621. 

  previously had a felony conviction for the same offense set aside under 

 has not 

 has 

 

 

 8.  The applicant is requesting that a first violation operating while intoxicated offense be set aside.  The applicant
   
  previously applied to have and had a first violation operating while intoxicated offense 
 has not 
 
    conviction set aside. 

 has 

Approved, SCAOForm MC 228, Rev. 3/23MCL 780.621, MCL 780.621b, MCL 780.621c, MCL 780.621d, MCL 780.622, MCL 780.623Page 1 of 3Distribute form to:CourtState PoliceArresting agencyProsecuting officialDefendantAttorney General 
 

 
 

 

 

 

 
 
 

 
 
 
 
 
 
 

 

     

  

     

  

 

Order on Application to Set Aside Conviction(s)  
Page 2 of 3

(3/23) 

Case No. 
 

 9. The time period required by MCL 780.621d for the conviction(s) listed in item 1 has passed for 
    a. 
    b. 

 all convictions. 
 the following convictions: 
 

 

 

 10.  The time period required by MCL 780.621d for the conviction(s) listed in item 1 has not passed for 
      a. 
      b. 

 all convictions. 
 the following convictions: 

 

 

  

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

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

 13.  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:  

 14.  The application is denied as to the following convictions listed in item 1:  

  
 
 

      Applicant may file another application to have this conviction 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

 .

 15.  The application is granted as to the following convictions listed in item 1: 

   

Date

   

      The following felony 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 of the applicant in each case to which this 
      order applies. If the conviction is for an 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, 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: Under MCL 780.622, if this order sets aside a conviction for a listed offense as defined in MCL 28.722 of the 
Sex Offenders Registration Act (SORA), you must still comply with the registration and reporting requirements of SORA for that offense 
until you present this order to the Department of State Police or the appropriate registering authority as provided in MCL 28.725(16).

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.

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, except for a first violation operating while intoxicated 
          offense, as defined in MCL 780.621(4)(d), if the person has not previously applied to have and had a first violation 
          operating while intoxicated offense conviction set aside under the act for setting aside convictions.  
      (ii) Any traffic 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.

MCL 780.621(4)(d) defines a first violation operating while intoxicated offense as a violation of any of the following committed 
by an individual who at the time of the violation has no prior convictions for violating section 625 of the Michigan vehicle 
code, 1949 PA 300, MCL 247.625:

(i)   Section 625(1), (2), (3), (6), or (8) of the Michigan vehicle code, 1949 PA 300, MCL 257.625.

(ii)   A local ordinance substantially corresponding to a violation listed in subparagraph (i).

(iii)  A law of an Indian tribe substantially corresponding to a violation listed in subparagraph (i).

(iv)  A law of another state substantially corresponding to a violation listed in subparagraph (i).

(v)   A law of the United States substantially corresponding to a violation listed in subparagraph (i).

 
 
 

 
 

 
 
 
 
 
 
 
 

 

 
 

 

   

   

 

 

Order on Application to Set Aside Conviction(s)  
Page 3 of 3

(3/23) 

Case No.