Criminal Record Sealing Pre-Registration Questionnaire
Please complete this form in order to determine your eligibility for record sealing and/or a certificate of qualified employment. 
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Full Legal Name *
Other names you’ve gone by, including maiden name, if applicable
Date of Birth
 *
MM
/
DD
/
YYYY
Last 4 digits of Social Security Number
 *
Email Address
 *
Phone Number
 *
Current Address
 *
Race *
Gender *
Are you employed? If so, where?
Job title
Approximate monthly HOUSEHOLD income (this is needed to determine if you’ll need to pay the court for your request to seal your record)
Do you have convictions in another state than Ohio? If so, which states?  
Do you have Federal convictions?
What counties and courts in Ohio do you have convictions in?
Are you currently on probation, controlled release, CCS, parole, or post release control? 
Are you currently facing pending criminal charges?
Do you have any felony convictions?
If so, what degree, if known?
Have you been convicted of any crimes of violence (examples can include but are not limited to assault, domestic violence, or menacing)?
Were you ordered to pay restitution and/or fines in any of your cases?
If so, are all paid in full?  It’s better to say unknown if you are not sure so we can double check.

I understand that any advice I receive through this clinic will not create an ongoing attorney-client relationship unless I and a participating attorney execute a separate, written, and signed representation agreement.

Initials to confirm understanding: 

I understand that filling out this pre-registration form does not guarantee me assistance. I understand that someone will follow up with me to let me know.

Initials to confirm understanding:

I understand that the determination of my eligibility for record sealing is based upon the information I have provided and Ohio public records that are available to the clinic.  I understand that my application could be denied because information regarding my criminal history was not provided or available to the Greater Dayton Volunteer Lawyers Project.

Initials to confirm understanding: 

I am a citizen of the United States. 

Provide name and date. 

I agree that information about my case may be shared with the following organizations: Advocates for Basic Legal Equality, Inc. (ABLE); Legal Aid of Western Ohio, Inc. (LAWO), Montgomery County Public Defender’s Office; or the Volunteer Lawyers Project of Greater Dayton; to find out whether those organizations can provide additional help for my case.

Provide name and date. 

After your case is reviewed for eligibility, we will contact you. We will attempt to make an appointment at that time. Please check your preferred method of contact. 
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