2021 RCCBA Expungement Clinic - Murfreesboro Criminal Defense & Divorce Attorney

REQUIRED ACKNOWLEDGEMENT AND DISCLOSURE *

I AGREE TO THE FOLLOWING:

THE 2021 RUTHERFORD COUNTY EXPUNGEMENT CLINIC INTAKE FORM IS FACILITATED ON THE WEBSITE OF THE LAW OFFICE OF W. SCOTT KIMBERLY; HOWEVER, THIS EVENT IS SPONSORED BY AND OPERATED BY THE RUTHERFORD AND CANNON COUNTY BAR ASSOCIATION. BY COMPLETING THIS FORM, YOU ACKNOWLEDGE THAT THE INFORMATION CONTAINED ON THIS FORM IS FOR THE SOLE PURPOSE OF SUBMITTING YOUR APPLICATION TO THE RUTHERFORD AND CANNON COUNTY BAR ASSOCIATION FOR THE EXPRESS PURPOSE OF THE EXPUNGEMENT CLINIC AND THAT THE SUBMISSION OF SUCH INFORMATION DOES NOT CREATE AN ATTORNEY - CLIENT RELEATIONSHIP WITH THE LAW OFFICE OF W. SCOTT KIMBERLY, PLLC, IT'S ATTORNEYS, OR EMPLOYEES. ALL INFORMATION SUBMITTED FOR THE EXPUNGEMENT CLINIC WILL BE DELETED AFTER THE APPLICATION IS PROCESSED.

1. PLEASE STATE YOUR FULL LEGAL NAME (FIRST, MIDDLE, LAST) *

EMAIL *

PHONE *

ADDRESS *

Address Line 1

Address Line 2

City

State

Zip Code

2. PLEASE LIST YOUR SOCIAL SECURITY NUMBER (XXX-XX-XXXX) *

Please note that the information collected here will be stored confidentially until the conclusion of the Expungement Clinic, at which time all information will be destroyed.

3. DO YOU HAVE ANY OUTSTANDING COURT COSTS *

YES
NO
I DO NOT KNOW

If the Answer is YES, please fill out Question #4. If the Answer is NO, please move on to Question #5

4. IF KNOWN, WHAT IS THE BALANCE OF YOUR COURT COSTS

If you do not know the balance of your court costs, please indicate here.

5. WERE YOU PLACED ON PROBATION *

YES
NO
NOT APPLICABLE / I DO NOT KNOW

If the Answer is YES, please fill out Questions #6 and #7. If the Answer is NO, please move on to Question #7

6. IF KNOWN, IS YOUR PROBATION PERIOD OVER *

YES
NO
NOT APPLICABLE / I DO NOT KNOW

7. IF KNOWN, HAVE YOU COMPLETED ALL CONDITIONS OF YOUR PROBATION *

YES
NO
NOT APPLICABLE / I DO NOT KNOW