Commonwealth of Pennsylvania 

v. 

In the Court of Common Pleas  
County of 

 Judicial District 

CRIMINAL DIVISION 

Docket No

ORDER 

AND NOW, this          day of 

, after consideration of the Petition for Limited Access

pursuant to Pa.R.Crim.P. 791 and 18 Pa.C.S. § 9122.1 presented by 

it is ORDERED that the petition is

The defendant's criminal history record information that is subject to limited access shall not be 

disseminated to an individual, a noncriminal justice agency or an internet website and that dissemination of the 

defendant's criminal history be limited only to criminal justice agency or government agency as provided in 18 

Pa.C.S. § 9122.1.   

are applicable.   

 

 

This case qualifies for a limited access order and none of the exceptions under 18 Pa.C.S. § 9122(b) 

The information required under Pa.R.Crim.P. 791 appears on the attached page(s) which is hereby 

incorporated into this ORDER by reference. 

BY THE COURT: 

_____________________   

1. Petitioner’s 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 Court of Common Pleas, Magisterial District or Philadelphia Municipal

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

7. Name and address of the affiant as shown on the complaint, if available:

8. Magisterial District Court or Philadelphia Municipal Court Number:

9. The Court of Common Pleas docket number:

10. Offense Tracking Number (OTN):

11. The date on complaint, or the date of arrest, and if available, the criminal justice agency that made

the arrest:

12. The specific charges, as they appear on the charging document, to be subject to limited access and

applicable dispositions (attach additional sheets if needed):

13. If the sentence includes restitution, and/or the fee authorized to carry out limited access, whether 

these amounts have been paid:

14. This case qualifies for a limited access order and none of the exceptions under 18 Pa.C.S. § 

9122.1(b) are applicable.

15. The reason(s) for this order for limited access: 

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