ACIC Form
7/27/2021
IN THE ______________COURT OF _________________, ARKANSAS
_________________ DIVISION
STATE OF ARKANSAS PLAINTIFF
vs. Case No. _____________
______________________________ DEFENDANT
(First, Middle and Last Name)
PETITION TO SEAL A MISDEMEANOR CONVICTION
FOR DRIVING OR BOATING WHILE INTOXICATED
Comes the Defendant and for his/her Petition to Seal the record states:
1. The Defendant was arrested on the ________ day of ___________,
_________, and charged with the offense(s) of Driving or Boating While
Intoxicated in violation of Ark. Code Ann. §5-65-103.
2. The Defendant either pled guilty or was found guilty of the offense(s) listed
above.
3. The Defendant has completed his or her sentence for this offense.
4. Defendant has paid all court costs unless payment has been excused by
the Court.
5. Defendant has paid all Court ordered Restitution, if any.
ACIC Form
7/27/2021
6. Defendant has paid all driver’s license suspension reinstatement fees and
completed all driver’s license reinstatement requirements if Defendant’s
driver’s license was suspended as a result of this plea or conviction.
7. Pursuant to Ark. Code Ann.§5-65-111(b)(1) and/or (c)(1), it has been more than
ten (10) years since Defendant’s first conviction for Driving or Boating While
Intoxicated.
8. [ ] Defendant has no pending felony charges in any state or federal court, or
[ ] Defendant has one or more pending felony charges in state or federal court
and the status of those charges is/are as follows:
________________________________________________________________
______________________________________________
9. Defendant [ ] IS or [ ] IS NOT required to register as a sex offender under the
Sex Offender Registration Act of 1997 (Ark. Code Ann.§12-12-901, et seq)
10. Defendant requests the Court enter a finding that he or she has been
rehabilitated.
11. As evidenced by my signature below, the above information is true and correct
to the best of Defendant’s knowledge.
WHEREFORE, the Defendant, _________________________, prays this Court enter
an order Sealing the above referenced misdemeanor conviction.
______________________________
Defendant’s Signature
_____________________________
Date
ACIC Form
7/27/2021
VERIFICATION
STATE OF ARKANSAS
COUNTY OF
Comes the Defendant/Petitioner, , under oath and states
that
the foregoing Petition is true and correct to the best of my knowledge
and belief.
Petitioner
Subscribed and sworn to before me on this ,
day of
, 20 .
(Seal)
Notary Public
My Commission expires:
THE FOLLOWING INFORMATION IS REQUIRED FOR PROPER
IDENTIFICATION OF THE DEFENDANT IN THE STATE AND
NATIONAL RECORD SYSTEMS
Race ____________ Arrest Tracking Number ________________
Sex ____________ SID No. _____________________
DOB ____________ FBI No. (If known)______________________
ACIC Form
7/27/2021
Certificate of Service
I, __________________________, do hereby certify that a true and correct
copy of the foregoing Petition has been provided to either the Prosecuting
Attorney for the County in which the Petition has been filed or to the City
Attorney depending on which office prosecuted the case and the arresting
agency by placing a copy of this Petition in the United States mail, postage
prepaid, to said office or by hand delivering a copy to said office.
___________________________
Defendant or Defendant’s Attorney
___________________________
Date
