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 ______________________. 

☐ Except as provided by law, all criminal justice agencies upon which this order is
served shall expunge and destroy the defendant’s arrest record, including the criminal
history record information, pertaining to the captioned proceedings.

☐ In accordance with Pa.R.Crim.P. 320, the criminal charges in the above-captioned
case specified below are dismissed and the defendant’s arrest records regarding these
charges shall be expunged except as provided by law.

☐ Except as provided by law, all criminal justice agencies upon which this order is
served shall expunge and destroy the official and unofficial arrest and other criminal
records pertaining to the captioned proceedings in accordance with Section 119 of The
Controlled Substance, Drug, Device and Cosmetic Act (35 P.S. § 780-119).

The information required under Pa.R.Crim.P. 790 appears on the attached page(s) which 
is hereby incorporated into this ORDER by reference. 

BY THE COURT: 

______________________________ 

AOPC Rev. 07/21/21

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Pursuant to Pa.R.Crim.P. 790, 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, if available:

8. Docket Number:  ________________________

9. Offense Tracking Number (OTN):  ________________________

10. The date on the 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. 07/21/2021 

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