Petition To Expunge (Remove) {NHJB-2619-P}

THE STATE OF NEW HAMPSHIRE JUDICIAL BRANCH http://www.courts.state.nh.us Court Name: Case Name: Case Number: (if known) Petition to Expunge founded report against PETITION TO EXPUNGE (REMOVE) (RSA 161-F:49, X) 1. Petitioner Name Residence Address Mailing Address (if different) Telephone Number (Home) 2. Victim's Name 3. Date of BEAS Finding Check the appropriate box or boxes Date of Birth (Work) County where incident occurred Abuse Neglect Exploitation 4. The petitioner states as follows: As of (date) my name is listed on the Bureau of Elderly and Adult Services (BEAS) State Registry of founded reports of abuse, neglect and exploitation. It has been (check one): More than one (1) year since the founded report against me and its entry onto the BEAS State Registry. Three (3) or more years since the denial of my last petition to have the founded report against me expunged (removed) from the BEAS State Registry. 5. Attached is a certified copy of my criminal record check results as required by RSA 161-F:49, X (b). 6. I certify that, since the date of the finding referenced in #4, there have been no other findings against me for abuse, neglect or exploitation against either an adult or a child. 7. In addition, I ask the court to consider the following information in support of the Petition to Expunge. (Attach additional pages if necessary.) 8. Please explain why you do not pose a present threat to the safety of individuals (adults and children). NHJB-2619-P (11/15/2010) Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com Case Name: Case Number: PETITION TO EXPUNGE 9. Please explain what efforts you have taken, if any, to eliminate the likelihood of recurrence of the type of behavior that resulted in the entry onto the registry. Upon the court's receipt and review of the information provided by BEAS, I request that the court grant this Petition to Expunge and order BEAS to remove the founded report from the Bureau of Elderly and Adult Services State Registry. I certify that a copy of this document has been provided to BEAS State Registry at 40 Terrill Park Drive, Concord NH 03301. Date Petitioner Signature State of This instrument was acknowledged before me on My Commission Expires Affix Seal, if any , County of by Signature of Notarial Officer / Title FOR COURT USE ONLY NOTICE TO BEAS STATE REGISTRY BEAS shall submit a report to the court within 30 days of this notice concerning all additional founded abuse, neglect or exploitation reports and other additional information relative to the petitioner. Date Court Staff Signature ORDER The Petition to Expunge is granted. The Bureau of Elderly and Adult Services shall remove the petitioner's founded report from the State Registry. The Petition to Expunge is denied. Date NHJB-2619-P (6/1/23) Judge Page 2 of 2 www.FormsWorkFlow.com