Expungement Intake Form

ZIP Code

Race / Ethnicity (select all that apply)

American Indian or Alaska Native Asian Black or African American Native Hawaiian or Other Pacific Islander White Hispanic or Latino Middle Eastern or North African Another race/ethnicity Prefer not to say

Background

Juvenile Court Information

If you have any questions about filling out this form, please email sblack@ujdrc.org.

Juvenile Court information is gathered to prepare the right paperwork for an expungement. If you're at all uncertain about your answer to a question in this section- please select 'unsure' and staff will follow up with you.

Were you ever on juvenile probation with Utah, but you were supervised in another state?

Yes No Unsure

If yes to the previous question- in which states, other than Utah, were you supervised on juvenile probation?

Were you ever in the Utah Division of Child and Family Services (DCFS) custody?

Yes No Unsure

Were you ever in the Utah Juvenile Justice Services (JJS) custody?

Yes No Unsure

Were you ever arrested as a juvenile in Utah, but charges were not filed?

Yes No Unsure

If yes to the previous question- provide dates and which law enforcement agency was involved.

Do you currently have any delinquency or criminal matters open?

Yes No Unsure

If yes, please describe any current case(s), court, and dates.

Adult History

If you have any questions about filling out this form, please email sblack@ujdrc.org.

Adult History information is gathered to prepare the right paperwork for an expungement.

Since you turned 18 years old, have you lived in a state besides Utah?

Yes No

If yes to the previous question- list each city and state where you have lived.

Schedule Clinic Appointment

Please select your top 3 time preferences for a virtual Zoom appointment on the clinic date. Within 7 business days of submitting this intake form, you will receive an email to tentatively*** confirm your appointment time.

***Your appointment will not be officially confirmed until you have completed supplemental documentation related to an expungement. You will receive information about how to complete the supplemental documentation via email.

Preference #1

Preference #2

Preference #3

Expungement Services

If you have any questions about filling out this form, please email inbox@ujdrc.org.

Are you willing to provide feedback about your experience with expungement services?

Yes No

If yes to the previous question- please provide your preferred contact method.

Expungement Intake Form

Contact Information

Background

Juvenile Court Information

Adult History

Schedule Clinic Appointment

Expungement Services