Personal Information

Conviction Details

This information can be found on the petitioner's criminal history record. Criminal history records can be requested from the California Department of Justice.

Case number:

Date of Conviction:

Petitioner's name as it appears in the charging document:

Please Select All That Apply

Please note that it is not required that the petitioner answer yes to each statement to be eligible for dismissal.
Statements in red are not applicable to the petitioner based on previous answers.

Felony or misdemeanor with probation granted (Penal Code section 1203.4)

Above, you indicated that

(a) probation was granted on the terms and conditions stated in the docket of the above-entitled court;
(b) petitioner is not serving a sentence for any offense; and
(c) petitioner is not under charge of commission of any crime.

To be eligible for relief under Section 1203.4, at least one of the following must be true. Please check all that apply.

Misdemeanor or infraction with sentence other than probation given (Penal Code section 1203.4a)

Above, you indicated that

(a) probation was not granted;
(b) more than one year has elapsed since the date of pronouncement of judgement;
(c) petitioner has complied with the sentence;
(d) petitioner is not serving a sentence for any offense; and
(e) the petitioner is not under charge of commission of any crime.

To be eligible for relief under Section 1203.4, one of the following must be true.

Misdemeanor conviction under Penal Code section 647(b) (Penal Code section 1203.49)

Above, you indicated that

(a) petitioner has completed a term of probation for a conviction under Penal Code section 647(b); and
(b) petitioner’s conviction was the result of his or her status as a victim of human trafficking.

To be eligible for relief under Section 1203.49, petitioner must establish by clear and convincing evidence that the conviction was the result of his or her status as a victim of human trafficking. Please provide that evidence in the box below.

Felony county jail sentence under Penal Code section 1170(h)(5) (Penal Code section 1203.41)

Above, you indicated that

(a) petitioner is not under supervision under Penal Code section 1170(h)(5)(B); and
(b) petitioner is not serving a sentence for, on probation for, or charged with the commission of any offense.

To be eligible for relief under Section 1203.41, one of the following must be true.

In addition, it must be the case that dismissal would serve the interests of justice. Please explain why granting dismissal would be in the interests of justice in the box below.

Felony prison sentence that would have been eligible for a felony county jail sentence after 2011 under Penal Code section 1170(h)(5) (Penal Code section 1203.42)

Above, you indicated that

(a) petitioner is not under supervision;
(b) petitioner is not serving a sentence for, on probation for, or charged with the commission of any offense; and
(c) more than two years have elapsed since petitioner completed the felony prison sentence.

To be eligible for relief under Section 1203.42, it must be the case that dismissal would serve the interests of justice. Please explain why granting dismissal would be in the interests of justice in the box below.

Deferred entry of judgment (Penal Code section 1203.43)

Above, you indicated that petitioner was granted a deferred entry of judgment and the criminal charges were dismissed under former Penal Code section 1000.3.

Date that charges were dismissed:

To be eligible for relief under Section 1203.43, it must be the case that one of the following is true.

Verify and Submit

By signing this form, you indicate under penalty of perjury under the laws of the State of California that the foregoing is true and correct.

Today's date:

Signature: