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Here is the text we could read:

This is a private record. 

 
 
 
 
 
 
 
Check your email. You will receive information and 
documents at this email address.  
 

I am   [  ]  Plaintiff/Petitioner 

[  ]  Plaintiff/Petitioner’s Attorney 

  (Utah Bar #:__________) 

In the [  ] District   [  ] Justice Court of Utah 

__________ Judicial District ________________ County 

Court Address ______________________________________________________ 

_____________________________________ 
Petitioner 
 

_______________________________ 
Case Number 

Petition to Expunge Records 
Cannabis Conviction 
Utah Code 77-40a-305((4) 

_______________________________ 
Judge 

Conviction record 
I was convicted of cannabis possession in court case number 
___________________.  

Certificate of eligibility  
I am not required to receive a certificate of eligibility for expungement to proceed 
with this petition. Utah Code 77-40a-305(4). 

Qualifying condition (Utah Code 26-61a-104) 
At the time of my arrest or citation leading to the conviction, I had the following 
qualifying condition which would have allowed me to use medical cannabis to 
treat symptoms (Choose all that apply): 

[  ]  HIV or acquired immune deficiency syndrome 

[  ]  Alzheimer's disease 

1003EXF Approved March 9, 2020 / 
Revised April 11, 2022 
 

Petition to Expunge Records – Cannabis Conviction 

Page 1 of 4 

 
Name 
 
Address 
 
City, State, Zip 
 
Phone 

 
Email  

n Re: 

  I

1. 

2. 

3. 

[  ]  amyotrophic lateral sclerosis 

[  ]  cancer 

[  ]  cachexia 

[  ]  persistent nausea not significantly responsive to traditional treatment, but 

not nausea related to: 
•  pregnancy; 
•  cannabis-induced cyclical vomiting syndrome; or 
•  cannabinoid hyperemesis syndrome 

[  ]  Crohn's disease or ulcerative colitis 

[  ]  epilepsy or debilitating seizures 

[  ]  multiple sclerosis or persistent and debilitating muscle spasms 

[  ]  post-traumatic stress disorder (meeting the requirements described in Utah Code 

26-61a-104(2)(j)) 

[  ]  autism 

six months 

[  ]  a terminal illness when the patient's remaining life expectancy is less than 

[  ]  a condition resulting in the individual receiving hospice care 

[  ]  a rare condition or disease that: 

•  affects less than 200,000 individuals in the United States, as defined in 

Section 526 of the Federal Food, Drug, and Cosmetic Act; and 
is not adequately managed despite treatment attempts using: 

• 

o  conventional medications other than opioids or opiates; or 
o  physical interventions; 

[  ]  pain lasting longer than two weeks that is not adequately managed, in the 
qualified medical provider's opinion, despite treatment attempts using: 
•  conventional medications other than opioids or opiates; or  
•  physical interventions 

[  ]  a condition approved by the Compassionate Use Board. I have attached 

proof of the Board's approval. 

1003EXF Approved March 9, 2020 / 
Revised April 11, 2022 
 

Petition to Expunge Records – Cannabis Conviction 

Page 2 of 4 

4. 
 

Form of cannabis (Utah Code 26-61a-102(32)) 
At the time of my arrest or citation leading to the conviction, the cannabis in my 
possession was in the following form to medicinally treat my condition (Choose all 
that apply). 

[  ]  Processed medical cannabis or a medical cannabis product: 

[  ]  a tablet 

[  ]  a capsule 

[  ]  a concentrated liquid or viscous oil 

[  ]  a liquid suspension 

[  ]  a topical preparation 

[  ]  a transdermal preparation 

[  ]  a sublingual preparation 

or rectangular cuboid shape 

[  ]  a resin or wax 

[  ]  a gelatinous cube, gelatinous rectangular cuboid, or lozenge in a cube 

[  ]  Unprocessed cannabis flower in a container described in Utah Code 4-

41a-602 that: 

• contains cannabis flowers in a quantity that varies by no more than 10% 

from the stated weight at the time of packaging;  

• at any time the medical cannabis cardholder transports or possesses the 
container in public, is contained within an opaque, child-resistant bag 
that the medical cannabis pharmacy provides; and 

• is labeled with the container’s content and weight, the date of purchase, 

the legal use termination date.  

[  ]  A form measured in grams, milligrams, or milliliters. 

5. 
 

Amount of cannabis (Utah Code 26-61a-102(16)) 
At the time of my arrest or citation leading to the conviction, the cannabis in my 
possession was in an amount to medicinally treat my condition and did not 
exceed (Choose all that apply): 

 

[  ]  113 grams by weight (unprocessed cannabis in a medicinal dosage form) 

[  ]  20 grams of total composite tetrahydrocannabinol (cannabis product in a 

medicinal dosage form) 

1003EXF Approved March 9, 2020 / 
Revised April 11, 2022 
 

Petition to Expunge Records – Cannabis Conviction 

Page 3 of 4 

7. 

Request 
I ask the court to order expungement of the record identified above, and order 
state, county and local government agencies to expunge related records in their 
possession or control. 

 declare under criminal penalty under the law of Utah that everything stated in this document is true. 

Signed at ______________________________________________________ (city, and state or country). 

Signature ► 

Printed Name 

 

 

       

    I

   

 
Date 

6. 

Public interest 
Expunging the crime(s) will not harm the public’s interests because:   

1003EXF Approved March 9, 2020 / 
Revised April 11, 2022 
 

Petition to Expunge Records – Cannabis Conviction 

Page 4 of 4

Petition to Expunge Records Cannabis Conviction

This info page is part of the LIT Lab's Form Explorer project. It is not associated with the Utah state courts. To learn more about the project, check out our about page.

Downloads: You can download both the original form (last checked 2023-03) and the machine-processed form with normalized data fields.

About This Form:

Sourced from legacy.utcourts.gov (2023-03)
Page(s): 4
Fields(s): 93
Average fields per page: 23
Reading Level: Grade 14
LIST Grouping(s): GO-00-00-00-00.

Use our Rate My PDF tool to learn more. Go beyond the above insights and learn more about this or any pdf form at RateMyPDF.com, includes: counts of difficult words used, passive voice decetion, and suggestions for how to make the form more usable.

Identified Data Fields:

We have done our best to automaticly identify and name form fields according to our naming conventions. When possible, we've used names tied to our question library. See e.g., user1_name. If we think we've found a match to a question in our library, it is highlighted in green. Novel names are auto generated. So, you will probably need to edit some of them if you're trying to stick to the convention.

Here are the fields we could identify.

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The Legal Innovation & Technology Lab's Form Explorer Beta @ Suffolk Law School Last updated 2023-04-02

Petition to Expunge Records Cannabis Conviction

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The Legal Innovation & Technology Lab's Form Explorer ^Beta @ Suffolk Law School Last updated 2023-04-02