Bedford County Expungement Clinic May 2, 2026

LAS Intake Form
Name*

First NameMiddle NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
African American/ BlackAsianCaucasian/ WhiteHispanicNative American IndianNative Hawaiian/ Other Pacific IslanferOther
Hispanic/Latino/SpanishNot Hispanic/Latino/SpanishOther
Birth Date*

MonthDayYear
FemaleMale
Primary Language *
Marital Status*
YesNo
YesNo
YesNo
YesNo
Citizenship Attestation I am a citizen of the United States of America.*
Victim of Sexual AssaultVictim of Domestic/Dating ViolenceVictim of StalkingVictim of Human TraffickingVictim of Elder AbuseIf you answered yes above, what is your relationship to the offender
For the following put 0 for any household member option that is not applicable to you.

Household Size*

Fill out the following fields to the best of your ability

I work and get paid Yes No*
I get paid $How much?*every *
How many hours do you work every week?*
How many miles do you drive to work one way?miles* miles.

Other forms of income

Expenses

Rows	My monthly expenses are:
Medical Insurance
Prescription Drugs
Child Care
Rent/ Mortgage
Utilities (water, heat, electricity)
Other

I have $How Much?* in the bank/cash.
Value of my personal possesions (not car or house) = $How Much* .
I own or am buying my home Yes No*

My home is worth $How Much?.
I owe $How Much? on my home.
I haveNumbercars.
The year/make/model of my car(s) is Type a label .
I owe $ Type a label on my car.

List every Tennessee county where you have arrests and/or convictions:*
List every county outside of Tennessee where you have arrests and/or convictions:*
List of every Federal Court where you have convictions:*
List every maiden name, alias, nickname, etc. under which your records may be found:*
Should be Empty:

LAS Intake Form