Form

Request to Restrict Record ( RR ) Form

REQUEST TO RESTRICT RECORD

For arrests after July 1, 2013

All fields are required.

Please complete and submit a separate form for each individual.

Full Name:

Date of Birth:

Race:

Sex:

Social Security Number:

Email:

Telephone Number:

Home Address:

Apt / Suite / Other:

City:

State:

Zip Code:

Arresting Agency:

Date of Arrest:

Offense(s) Arrested For

Were you convicted/found guilty/pleaded guilty/pleaded nolo?

If so, what was your sentence?

This form must be completed in its entirety before request may be submitted to the Prosecuting Attorney's Office.

I request the record information (Date of Arrest and associated charges) described above pertaining to me be restricted from the record(s) of the arresting agency pursuant to the provisions of O.C.G.A. §35-3-37.

Signature (Enter full name)

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Request to Restrict Record ( RR ) Form

REQUEST TO RESTRICT RECORD

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Request to Restrict Record ( RR ) Form

REQUEST TO RESTRICT RECORD

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