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IN THE OREGON CIRCUIT COURT

_________________ COUNTY

IN RE:

_______________________,

Petitioner.

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Case No. ______________

DECLARATION IN SUPPORT OF
MOTION FOR ORDER TO SET ASIDE
CONVICTION

I DECLARE:
I am the Defendant in the above-entitled matter. I submit this DECLARATION in
support of the attached Motion to Set Aside CONVICTION;

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The information pertaining to this matter as set out in the Motion is true to the

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best of my knowledge and belief;

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More than three (3) years have elapsed since the date of pronouncement of judgment;
I have fully complied with and performed the sentence of the Court;

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I HAVE NOT BEEN CONVICTED OF OR ARRESTED FOR AN OFFENSE PUNISHABLE

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AS A FELONY, MISDEMEANOR OR VIOLATION, EXCEPT AS SPECIFIED HEREIN;

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I do not have any criminal charges pending against me at this time;

I have not previously had a conviction set aside by order of any Court.

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I HEREBY DECLARE THAT THE ABOVE STATEMENT IS TRUE TO THE BEST OF

MY KNOWLEDGE AND BELIEF, AND THAT I UNDERSTAND IT IS MADE FOR USE
AS EVIDENCE IN COURT AND IS SUBJECT TO PENALTY FOR PERJURY.
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Date:_______________
Defendants Signature