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: Required

Date of Birth: Required

Race: Required

Sex: Required

Social Security Number: Required

Email: Required

Telephone Number: Required

Home Address: Required

Apt / Suite / Other:

City: Required

State: Required

Zip Code: Required

Arresting Agency: Required

Date of Arrest: Required

Offense(s) Arrested For Required

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

If so, what was your sentence? Required

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) Required

Text Verification Required