Pursuant to K.S.A. 21-2511 and K.A.R. 10-21-4

Please complete all fields of information in this application and provide copies of all supporting documentation. Supporting documentation may include:

a copy of the prosecutor’s declination to charge;

a certified copy of the court’s final order determining there was no probable cause for the arrest, charge, or placement in custody for the qualifying offense; or

a certified copy of the court’s order of reversal, dismissal, acquittal, or pardon for each qualifying offense.

The expungement process will cease unless all information is provided in the application and is submitted along with all supporting documentation.

The information in this box is required for expungement
Applicant to be Expunged:
Name:
Date of Birth:	Social Security #:	Male:	Female:
Race:	Place of Birth:
County where arrested, charged or convicted of qualifying offense (whichever is applicable):
District Court Case #:
Offenses:
Contact Information for Applicant or Applicant’s Representative:
Name:
Address:
City	State	Zip
Telephone #:	( ) -	E-mail Address:

Submit to:	Kansas Bureau of Investigation Legal Division

1620 S.W. Tyler

Topeka, Kansas 66612