CCRP 993     

Art. 993. Supplemental forms to be used

            SUPPLEMENTAL SHEET

            ____ Yes ____ No    ARRESTS THAT DID NOT RESULT IN CONVICTION

            NO. ___                      La. Rev. Stat. Ann.                             § _______ : ________

                                                Name of the offense                             _________________

                                                ( ) Time expired for prosecution        _____/____/_______

                                                                                                            (MM/DD/YYYY)

                                                ( ) Charge refused by DA - not prosecuted.

                                                ( ) Pre-trial Diversion Program.

                                                ( ) Charge dismissed

                                                ( ) Found not guilty/judgment of acquittal

            NO. ___                      La. Rev. Stat. Ann.                             § _______ : ________

                                                Name of the offense                             _________________

                                                ( ) Time expired for prosecution        _____/____/_______

                                                                                                            (MM/DD/YYYY)

                                                ( ) Charge refused by DA - not prosecuted.

                                                ( ) Pre-trial Diversion Program.

                                                ( ) Charge dismissed

                                                ( ) Found not guilty/judgment of acquittal

            NO. ___                      La. Rev. Stat. Ann.                             § _______ : ________

                                                Name of the offense                             _________________

                                                ( ) Time expired for prosecution        _____/____/_______

                                                                                                            (MM/DD/YYYY)

                                                ( ) Charge refused by DA - not prosecuted.

                                                ( ) Pre-trial Diversion Program.

                                                ( ) Charge dismissed

                                                ( ) Found not guilty/judgment of acquittal

            NO. ___                      La. Rev. Stat. Ann.                             § _______ : ________

                                                Name of the offense                             _________________

                                                ( ) Time expired for prosecution        _____/____/_______

                                                                                                            (MM/DD/YYYY)

                                                ( ) Charge refused by DA - not prosecuted.

                                                ( ) Pre-trial Diversion Program.

                                                ( ) Charge dismissed

                                                ( ) Found not guilty/judgment of acquittal

            NO. ___                      La. Rev. Stat. Ann.                             § _______ : ________

                                                Name of the offense                             _________________

                                                ( ) Time expired for prosecution        _____/____/_______

                                                                                                            (MM/DD/YYYY)

                                                ( ) Charge refused by DA - not prosecuted.

                                                ( ) Pre-trial Diversion Program.

                                                ( ) Charge dismissed

                                                ( ) Found not guilty/judgment of acquittal

            NO. ___                      La. Rev. Stat. Ann.                             § _______ : ________

                                                Name of the offense                             _________________

                                                ( ) Time expired for prosecution        _____/____/_______

                                                                                                            (MM/DD/YYYY)

                                                ( ) Charge refused by DA - not prosecuted.

                                                ( ) Pre-trial Diversion Program.

                                                ( ) Charge dismissed

                                                ( ) Found not guilty/judgment of acquittal

SUPPLEMENTAL SHEET

            ____ Yes ____ No    MISDEMEANOR CONVICTIONS

            NO. ___                      La. Rev. Stat. Ann.                             § _______ : ________

                                                Name of the offense                             _________________

                                                ( ) Conviction set aside/dismissed      _____/____/_______

                                                                                                            (MM/DD/YYYY)

                                                       pursuant to C.Cr.P. Art. 894(B)

                                                ( ) More than 5 years have passed

                                                       since completion of sentence.

            NO. ___                      La. Rev. Stat. Ann.                             § _______ : ________

                                                Name of the offense                             _________________

                                                ( ) Conviction set aside/dismissed      _____/____/_______

                                                                                                            (MM/DD/YYYY)

                                                       pursuant to C.Cr.P. Art. 894(B)

                                                ( ) More than 5 years have passed

                                                       since completion of sentence.

            NO. ___                      La. Rev. Stat. Ann.                             § _______ : ________

                                                Name of the offense                             _________________

                                                ( ) Conviction set aside/dismissed      _____/____/_______

                                                                                                            (MM/DD/YYYY)

                                                       pursuant to C.Cr.P. Art. 894(B)

                                                ( ) More than 5 years have passed

                                                       since completion of sentence.

            NO. ___                      La. Rev. Stat. Ann.                             § _______ : ________

                                                Name of the offense                             _________________

                                                ( ) Conviction set aside/dismissed      _____/____/_______

                                                                                                            (MM/DD/YYYY)

                                                       pursuant to C.Cr.P. Art. 894(B)

                                                ( ) More than 5 years have passed

                                                       since completion of sentence.

            NO. ___                      La. Rev. Stat. Ann.                             § _______ : ________

                                                Name of the offense                             _________________

                                                ( ) Conviction set aside/dismissed      _____/____/_______

                                                                                                            (MM/DD/YYYY)

                                                       pursuant to C.Cr.P. Art. 894(B)

                                                ( ) More than 5 years have passed

                                                       since completion of sentence.

            NO. ___                      La. Rev. Stat. Ann.                             § _______ : ________

                                                Name of the offense                             _________________

                                                ( ) Conviction set aside/dismissed      _____/____/_______

                                                                                                            (MM/DD/YYYY)

                                                       pursuant to C.Cr.P. Art. 894(B)

                                                ( ) More than 5 years have passed

                                                       since completion of sentence.

            NO. ___                      La. Rev. Stat. Ann.                             § _______ : ________

                                                Name of the offense                             _________________

                                                ( ) Conviction set aside/dismissed      _____/____/_______

                                                                                                            (MM/DD/YYYY)

                                                       pursuant to C.Cr.P. Art. 894(B)

                                                ( ) More than 5 years have passed

                                                       since completion of sentence.

            NO. ___                      La. Rev. Stat. Ann.                             § _______ : ________

                                                Name of the offense                             _________________

                                                ( ) Conviction set aside/dismissed      _____/____/_______

                                                                                                            (MM/DD/YYYY)

                                                       pursuant to C.Cr.P. Art. 894(B)

                                                ( ) More than 5 years have passed

                                                       since completion of sentence.

            NO. ___                      La. Rev. Stat. Ann.                             § _______ : ________

                                                Name of the offense                             _________________

                                                ( ) Conviction set aside/dismissed      _____/____/_______

                                                                                                            (MM/DD/YYYY)

                                                       pursuant to C.Cr.P. Art. 894(B)

                                                ( ) More than 5 years have passed

                                                       since completion of sentence.

SUPPLEMENTAL SHEET

            ____ Yes ____ No    FELONY CONVICTIONS

            NO. ___                      La. Rev. Stat. Ann.                             § _______ : ________

                                                Name of the offense                             _________________

                                                ( ) Conviction set aside/dismissed      _____/____/_______

                                                                                                            (MM/DD/YYYY)

                                                       pursuant to C.Cr.P. Art. 893(E)

                                                ( ) More than 10 years have passed

                                                       since completion of sentence

            NO. ___                      La. Rev. Stat. Ann.                             § _______ : ________

                                                Name of the offense                             _________________

                                                ( ) Conviction set aside/dismissed      _____/____/_______

                                                                                                            (MM/DD/YYYY)

                                                       pursuant to C.Cr.P. Art. 893(E)


                                                ( ) More than 10 years have passed

                                                       since completion of sentence

            NO. ___                      La. Rev. Stat. Ann.                             § _______ : ________

                                                Name of the offense                             _________________

                                                ( ) Conviction set aside/dismissed      _____/____/_______

                                                                                                            (MM/DD/YYYY)

                                                       pursuant to C.Cr.P. Art. 893(E)

                                                ( ) More than 10 years have passed

                                                       since completion of sentence

            NO. ___                      La. Rev. Stat. Ann.                             § _______ : ________

                                                Name of the offense                             _________________


                                                ( ) Conviction set aside/dismissed      _____/____/_______

                                                                                                            (MM/DD/YYYY)

                                                       pursuant to C.Cr.P. Art. 893(E)

                                                ( ) More than 10 years have passed

                                                       since completion of sentence

            NO. ___                      La. Rev. Stat. Ann.                             § _______ : ________

                                                Name of the offense                             _________________

                                                ( ) Conviction set aside/dismissed      _____/____/_______

                                                                                                            (MM/DD/YYYY)

                                                      pursuant to C.Cr.P. Art. 893(E)

                                                ( ) More than 10 years have passed

                                                       since completion of sentence

            NO. ___                      La. Rev. Stat. Ann.                             § _______ : ________

                                                Name of the offense                             _________________

                                                ( ) Conviction set aside/dismissed      _____/____/_______

                                                                                                            (MM/DD/YYYY)

                                                       pursuant to C.Cr.P. Art. 893(E)

                                                ( ) More than 10 years have passed

                                                       since completion of sentence

            NO. ___                      La. Rev. Stat. Ann.                             § _______ : ________

                                                Name of the offense                             _________________

                                                ( ) Conviction set aside/dismissed      _____/____/_______

                                                                                                            (MM/DD/YYYY)

                                                       pursuant to C.Cr.P. Art. 893(E)

                                                ( ) More than 10 years have passed

                                                       since completion of sentence

            NO. ___                      La. Rev. Stat. Ann.                             § _______ : ________

                                                Name of the offense                             _________________

                                                ( ) Conviction set aside/dismissed      _____/____/_______

                                                                                                            (MM/DD/YYYY)

                                                       pursuant to C.Cr.P. Art. 893(E)

                                                ( ) More than 10 years have passed

                                                       since completion of sentence

            NO. ___                      La. Rev. Stat. Ann.                             § _______ : ________

                                                Name of the offense                             _________________

                                                ( ) Conviction set aside/dismissed      _____/____/_______

                                                                                                            (MM/DD/YYYY)

                                                       pursuant to C.Cr.P. Art. 893(E)

                                                ( ) More than 10 years have passed

                                                       since completion of sentence


            Acts 2014, No. 145, §1; Acts 2018, No. 711, §1.