Commonwealth of Pennsylvania 

v. 

IN THE COURT OF COMMON PLEAS OF 
__________________________ COUNTY, 
PENNSYLVANIA 

______________________ 

CRIMINAL DIVISION 

DOCKET NO:  ______________________ 

ORDER 

AND NOW, this ____ day of ____________, 20___, after consideration of the 
_______________________________________ presented by ______________________, 
it is ORDERED that the Petition/Motion is ______________________. 

☐ The criminal charges in the above-captioned case specified below are dismissed.

☐ The defendant's arrest record regarding these charges shall be expunged.  Further,
it is ORDERED that the arresting agency shall destroy all criminal records, fingerprints,
photographic plates and photographs pertaining to the charge(s) specified below, which
resulted from the arrest(s) of _______________________________________.

☐ In  addition,  all  criminal  justice  agencies  upon  which  this  order  is  served  shall
expunge and destroy the official and unofficial arrest and other criminal records, files
and other documents pertaining to the captioned proceedings.

The information required under Pa.R.Crim.P. 490 appears on the attached page(s) 

 
which is hereby incorporated into this ORDER by reference. 

BY THE COURT: 

______________________________ 

AOPC Rev. 03/06/14 

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Pursuant to Pa.R.Crim.P. 490, the following information is provided: 

1. Petitioner Name:  _______________________________________________________

2. Alias(es): ____________________  ____________________  ____________________

3. Petitioner’s Address:  ____________________________________________________

4. Petitioner’s Date of Birth:  ____________

5. Petitioner’s Social Security Number:   _______________

6. Name and address of the judge of the Court of Common Pleas or Philadelphia

Municipal Court who accepted the guilty  plea or heard the case:

7. Name and mailing address of the affiant as shown on the complaint or citation, if

available:

8. Magisterial District Court number:  ________________________

9. Docket Number:  ________________________

10. The date on the citation or complaint, or the date of arrest, and if available, the criminal

justice agency that made the arrest:

11. The specific charges, as they appear on the charging document, to be expunged and

applicable dispositions (attach additional sheets if needed):

12. If the sentence includes a fine, costs, or restitution, whether the amount due has been

paid:  ____________________

13. The reason for expungement:

14. The criminal justice agencies upon which certified copies of the order shall be served:

AOPC Rev. 03/06/14 

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