Dj Le 250B Form – Fill Out and Use This PDF

INSTRUCTIONS FOR COMPLETING A

WISCONSIN &/E'ZWZ/EdZKZREMOVALREQUEST

All ILQJHUSULQW UHFRUG removals will be in compliance with Wisconsin State Statute 165.(). The use of this form is intended to safeguard the rights of the signatory and to ensure proper removal of the record. Legible inked fingerprint impressions are mandatory to verify the identity of the requester with the record, should one exist. Any law enforcement agency can assist in obtaining the inked, rolled fingerprint impression. If either finger is injured, provide

the impression of another finger, but clearly designate which fingers were used for the rolled impression.

1.All record removal requests must be made by the requesting candidate using the Wisconsin )LQJHUSULQW 5HFRUG

Removal 5equest Form (DJ-LE-%), and sent to the &ULPH ,QIRUP WLRQ %XUH X$WWQ&ULPLQ O+LVWRU\8QLW32%R[ 0 GLVRQ:,.7KLVIRUPP \QRW H VX PLWWHG \I [

2.The form must be completed fully, including all identifying information, two fingerprints and F QGLG WH VVLJQ WXUH

a.Conviction information must include court case number and charge. This information may be found on CCAP (Wisconsin Circuit Court Access) http://wcca.wicourts.gov/index.xslRU WKURXJKWKH0XQLFLS O&RXUWIRURUGLQ QFH

RIIHQVHV.

b. If the request is	subsequent to a	conviction,	finding,	or	an	adjudication, supporting documentation
must be provided,	which shall include	a certified	copy of	the	court	order reversing, setting aside, or vacating
the conviction.

. 2ne of the following parameters must be met before arrest ILQJHUSULQWVcan be removed:

a.All RIIHQVHVUHSRUWHGRQWKH UUHVWILQJHUSULQWF UGPXVWK YHUHVXOWHGLQ\RX HLQJUHOH VHG ZLWKRXW FK UJH RU

QRW SURVHFXWHG RU \RX HLQJ FOH UHG RI OO RIIHQVHV WKURXJK FRXUW SURFHHGLQJV Dismissal of only some of the offenses but convictions on others precludes the removal of the record. Convictions on lesser offenses also precludes removal of the record.

b.&RPSOHWLRQRI ILUVWRIIHQGHUSURJU P deferred prosecution ZKLFKUHVXOWVLQQRSURVHFXWLRQ RU GLVPLVV O TX OLILHV

IRU UHPRY O SURYLGLQJ GRFXPHQW WLRQ LV SURYLGHG VKRZLQJ VXFFHVVIXO FRPSOHWLRQ ORQJ ZLWK SURRI RI GLVPLVV O RU QR SURVHFXWLRQ Supporting documentation must accompany this request.

c.,IWKHUHTXHVWLVIRUUHPRY ORIMXYHQLOH UUHVWLQIRUP WLRQXQGHUSULRUWR QG XQGHU IWHU IRUVW WHFK UJHV QGIRURUGLQ QFHFK UJHV GRFXPHQW WLRQRIWKHGLVPLVV ORUQR SURVHFXWLRQ0867 FFRPS Q\WKHUHTXHVW

4.A court ordered expungement under s. 973.015 Wis. Stats. does not qualify for expungement from the state criminal history record since the case resulted in a conviction. CRXUW RUGHUHG H[SXQJHPHQWVRUVHQWHQFLQJXQGHU \RXWKIXORIIHQdHUSURYLVLRQVWLOOUHVXOWVLQ FRQYLFWLRQ QGZRXOG SUHFOXGHWKHUHPRY ORIWKHILQJHUSULQWUHFRUG Court ordered

expungement seals the court files but has no effect on files maintained by the Wisconsin Department of Justice. Removal of

arrest information from the Department of Justice files has no effect on the availability of the same information from court files or police records. State v. Leitner, 2002 WI 77, 253 Wis. 2d 449, 646 N.W.2d 341, 00-1718.

5. Not all	offenses are reported to the Department	of	ustice.	If you were not fingerprinted for the requested
offense,	the Department of ustice will not have	a	record of	that offense and it will not appear on your state criminal
history record.

6.Successful requests will result in either the return of the arrest fingerprint card or deletion of the electronically stored

document. ,I WKH ILQJHUSULQW UHFRUG HLQJ UHPRYHG IURP WKH 'HS UWPHQW RI -XVWLFH UHFRUG Z V UHSRUWHG WR WKH )HGHU O %XUH X RI ,QYHVWLJ WLRQ )%, WKH 'HS UWPHQW RI -XVWLFH ZLOO QRWLI\ WKH )%, WR UHPRYH WK W LQIRUP WLRQIURPWKH)%,ILOH

7.Time to process a request varies. If your request qualifies and the disposition has been reported to the Department of Justice your request will be processed promptly. If the disposition has not been submitted by the court, prosecutor or arresting agency, staff will need to obtain the disposition, make sure the disposition qualifies the removal of the record, update the

criminal history and then process the request. If you have documentation regarding the dismissal of the offense(s) involved in your request, you should include copies with the request to speed processing.

DJ-LE- ͕ REV. DATE 02/23/2017

WISCONSIN FINGERPRINT RECORD REMOVAL REQUEST

I hereby request that the Crime Information Bureau, Division of Law Enforcement Services of the Wisconsin Department of Justice, remove the following described fingerprint record, if it exists, pursuant to Wisconsin Statute 165.84 (1). The information provided below must match the information furnished by the arresting agency at

DJ-LE-250B 02/23/2017 the time of the arrest.

Person Submitting the Request (Print or Type)

LAST NAME:

IRST NAME:

F

LL MIDDLE NAME:

675((7 ''5(66:

570(17180 (5:

&,7 :

67 7(:

=,

:

Subject of the Record and Arrest to be Removed (Print or Type)

LAST NAME:

IRST NAME:

F LL MIDDLE NAME:

GENDER:

RAC :

DATE OF BIRTH (mm/dd/yyyy):

Male

Female

__ __ / __

__ / ____

____

DATE OF ARR ST:

ARR STIN

AGENCY

ARR STIN

A

NC

CAS

DATE OF CON ICTION OR AD

DICATION :

NA

O CO RT

CHARGE & DISPOSITION

DATE OF ARR ST:

ARR STIN

AGENCY

ARR STIN

A

NC

CAS

DATE OF CON ICTION OR AD

DICATION :

NA

O CO RT

CHARGE & DISPOSITION

DATE OF ARR ST:

ARR STIN

AGENCY

ARR STIN

A

NC

CAS

DATE OF CON ICTION OR AD

DICATION :

NA

O CO RT

CHARGE & DISPOSITION

If necessary to proceed with your fingerprint record removal request, the signature below also represents a request to expunge your DNA Databank Record at the Wisconsin State Crime Laboratory.

I attest that all the information provided is accurate and true to the best of my knowledge.

Signature of Requester:

Date:

FINGERPRINTS

Place one fingerprint from each of the subject's index fingers in the boxes to

the right. This fingerprint will be used to confirm the identity of the subject.

LEFT INDEX FINGER

DO NOT WRITE BELOW THIS LINE

Request Number

or DL S se Only