Record Clearing Eligibility TestPlease fill out this form to see if you are eligible to vacate your criminal work conviction Name * First Name Last Name Date of Birth MM DD YYYY 1) What best describes your criminal record? (Check one) (If you have both adult and juvenile records, you will need to determine your eligibility on a case-by-case basis) Adult arrest without conviction (including deferred, diversion, & dismissed cases) Adult conviction Juvenile conviction 2) Have you completed your sentence and been discharged from court supervision? (Check one) Yes No 3) Are any criminal charges pending against you in state or federal court? (Check one) Yes No 4) Is it a felony or a misdemeanor? (Check one) (The classification at the time of the arrest does not matter. We just need to know what it was at the time you were convicted) Felony Misdemeanor 5) Have you been convicted of another crime in any state or federal court since the conviction? (Check one) Yes No 6) Was the offense a violent offense or an attempt to commit a violent offense? (Check one) (See definition in RCW 9.94A.30 below) Violent offense means any of the following felonies: •Any felony defined under any law as a class A felony or an attempt to commit a class A felony; •Criminal solicitation of or criminal conspiracy to commit a class A felony; •Manslaughter in the first degree; •Manslaughter in the second degree; •Indecent liberties if committed by forcible compulsion; •Kidnapping in the second degree; •Arson in the second degree; •Assault in the second degree; •Assault of a child in the second degree; •Extortion in the first degree; •Robbery in the second degree; •Drive-by shooting; •Vehicular assault, when caused by the operation or driving of a vehicle by a person while under the influence of intoxicating liquor or any drug or by the operation or driving of a vehicle in a reckless manner; •Vehicular homicide, when proximately caused by the driving of any vehicle by any person while under the influence of intoxicating liquor or any drug as defined by RCW 46.61.502, or by the operation of any vehicle in a reckless manner Yes No 7) Was the offense RCW 46.61.502 (driving while under the influence), 46.61.504 (actual physical control while under the influence), or 9.91.020 (operating a railroad, etc. while under the influence)? (Check one) Yes No 8) Was the offense RCW 9.68 (obscenity and pornography) 9.68A (sexual exploitation of children), 9A.44 (sex offenses), or the attempt of any of these? (Check one) Yes No 9) Was the offense domestic violence? (Check one) If you selected Yes to Question No. 9, proceed to Question No. 10 If you selected No to Question No. 9, proceed to Question No. 11 Yes No 10) Do you have a previous conviction for domestic violence? (Check one) Yes No 11) Have you ever had the record of another conviction vacated? (Check one) Yes No 12) Do you have a protective order, no-contact order, anti-harassment order, or civil restraining order against you or have had one within the last 5 years? (Check one) Yes No 13) Have you met the waiting periods listed below from discharge of court supervision without a criminal conviction (including paying all fines and finishing requirements)? (Check one) • Domestic Violence - 5 years • Misdemeanor - 3 years • Gross Misdemeanor - 3 years Yes No Case Number: Full Name at the Time of Offense: Date Arrested: MM DD YYYY Date Convicted: MM DD YYYY County of Offense Class of Offense(s) (if known): Name of Offense Did you receive probation? (Check one) If you selected Yes to this Question, proceed to the next. If you selected No to this Question, proceed to submit Yes No Did you violate probation? Yes No How long were you on probation? Thank you!
