Petition for Certificate of Rehabilitation and Pardon Penal Code 4852.01 Page 1 of 7 ATTORNEY OR PARTY WITHOUT ATTORNEY (Name & Address): Fax No. (Optional): Telephone No.: E-Mail Address (Optional): ATTORNEY FOR (Name): Bar No: FOR C O UR T U S E O NL Y SUPERIOR COURT OF CALIFORNIA, COUNTY OF In t h e M a tter of t h e A pp l i c a t i on of T y p e P e t i t io n e r s f u l l n a m e F i r s t M iddl e La s t a n d S u f f i x , i f appl i ca b l e D a te o f B i rt h : CII N um b e r: Cr imi n a l C a s e N u mbe r ( s ): PE T I T I O N FO R C E R T I F IC A T E O F R E H A BI L I T A T I O N A ND P A RD O N ( P en a l C ode 4 85 2 .01 et s eq.) CASE NUMBER: To the Superior Court of California, County of : The above-named petitioner represents and shows that: CONVICTION HISTORY [All qualifying convictions must be listed. If you have more than three (3) qualifying convictions, attach additional sheets following the same format.] Most Recent Qualifying Conviction (A) Offense On or about , petitioner was convicted of the crime of Month Day, Year Indicate Crime and Code Section on case number: in the County of , California. (B) Type of Sentence or Disposition Petitioners sentence for this offense was: [Check the appropriate box] Commitment to state prison or other state institution at ; Name of institution or city where located Sentenced to county jail pursuant to Penal Code 1170(h) at ; Name of county where located Sentenced to state prison, but execution of sentence was suspended and petitioner was placed on probation. Imposition of sentence was suspended and petitioner was placed on probation. American LegalNet, Inc. www.FormsWorkFlow.com Name: Case Number: Petition for Certificate of Rehabilitation and Pardon Penal Code 4852.01 Page 2 of 7 (C) Date of Release Thereafter, on or about , petitioner was; Date released from custody [Check the appropriate box(es)] Discharged from state prison or other state institution after completing his/her sentence on (date). Released on parole on (date). Released from county jail pursuant to Penal Code 1170(h) (no mandatory supervision) on date). Released from county jail to serve mandatory supervision pursuant to Penal Code 1170(h) on (date). Released from custody on probation (after serving a jail sentence as a condition of probation) on (date). Released on probation (if no jail sentence was imposed) on (date). (D) Penal Code 1203.4 History (For Probationers Only) A. After termination of probation on , a petition for relief under Penal Code section 1203.4 was granted on (date). B. Has petitioner been incarcerated in any prison, jail, detention facility, or other penal institution or agency after his/her Penal Code section 1203.4 petition was granted? Yes No C. If yes, when and where? D. Is petitioner currently on probation or mandatory supervision for the commission of any other felony? Yes No E. Petitioner presents the following evidence that he/she has resided in California for the past five years (supporting documentation may be attached as exhibits to the petition): (E) Penal Code 1203.41 History (For sentences pursuant to PC 1170(h) only) a)A petition for relief under Penal Code section 1203.41 was granted on (date).b)Has petitioner been incarcerated in any prison, jail, detention facility, or other penal institution or agency after his/herPenal Code section 1203.41 petition was granted? Yes Noc)If yes, when and where? .d)Is petitioner currently on probation for the commission of any other felony? Yes Noe)Petitioner presents the following evidence that he/she has resided in California for the past five years (supportingdocumentation may be attached as exhibits to the petition): American LegalNet, Inc. www.FormsWorkFlow.com Name: Case Number: Petition for Certificate of Rehabilitation and Pardon Penal Code 4852.01 Page 3 of 7 Second Most Recent Qualifying Conviction (A) Offense On or about , petitioner was convicted of the crime of Month Day, Year Indicate Crime and Code Section on case number: in the County of , California. (B) Type of Sentence or Disposition Petitioners sentence for this offense was: [Check the appropriate box] Commitment to state prison or other state institution at ; Name of institution or city where located Sentenced to county jail pursuant to Penal Code 1170(h) at ; Name of county where located Sentenced to state prison, but execution of sentence was suspended and petitioner was placed on probation. Imposition of sentence was suspended and petitioner was placed on probation. (C) Date of Release Thereafter, on or about , petitioner was; Date released from custody [Check the appropriate box(es)] Discharged from state prison or other state institution after completing his/her sentence on (date). Released on parole on (date). Released from county jail pursuant to Penal Code 1170(h) (no mandatory supervision) on (date; Released from county jail to serve mandatory supervision pursuant to Penal Code 1170(h) on (date; Released from custody on probation (after serving a jail sentence as a condition of probation) on (date). Released on probation (if no jail sentence was imposed) on (date). (D) Penal Code 1203.4 History (For Probationers Only) A. After termination of probation on , a petition for relief under Penal Code section 1203.4 was granted on (date). B. Has petitioner been incarcerated in any prison, jail, detention facility, or other penal institution or agency after his/her Penal Code section 1203.4 petition was granted? Yes No C. If yes, when and where? D. Is petitioner currently on probation or mandatory supervision for the commission of any other felony? Yes No E. Petitioner presents the following evidence that he/she has resided in California for the past five years (supporting documentation may be attached as exhibits to the petition): American LegalNet, Inc. www.FormsWorkFlow.com Name: Case Number: Petition for Certificate of Rehabilitation and Pardon Penal Code 4852.01 Page 4 of 7 (E) Penal Code 1203.41 History (For sentences pursuant to PC 1170(h) only) a)A petition for relief under Penal Code section 1203.41 was granted on (date).b)Has petitioner been incarcerated in any prison, jail, detention facility, or other penal institution or agency after his/herPenal Code section 1203.41 petition was granted? Yes Noc)If yes, when and where? .d)Is petitioner currently on probation for the commission of any other felony? Yes Noe)Petitioner presents the following evidence that he/she has resided in California for the past five years (supportingdocumentation may be attached as exhibits to the petition): Third Most Recent Qualifying Conviction (A) Offense On or about , petitioner was convicted of the crime of Month Day, Year Indicate Crime and Code Section on case number: in the County of , California. (B) Type of Sentence or Disposition Petitioners sentence for this offense was: [Check the appropriate box] Commitment to state prison or other state institution at ; Name of institution or city where located Sentenced to county jail pursuant to Penal Code 1170(h) at ; Name of county where located Sentenced to state prison, but execution of sentence was suspended and petitioner was placed on probation. Imposition of sentence was suspended and petitioner was placed on probation. (C) Date of Release Thereafter, on or about , petitioner was; Date released from custody [Check the appropriate box(es)] Discharged from state prison or other state institution after completing his/her sentence on (date). Released on parole on (date). Released from county jail pursuant to Penal Code 1170(h) (no mandatory supervision) on (date; Released from county jail to serve mandatory supervision pursuant to Penal Code 1170(h) on (date; Released from custody on probation (after serving a jail sentence as a condition of probation) on (date). Released on probation (if no jail sentence was imposed) on (date). American LegalNet, Inc. www.FormsWorkFlow.com Name: Case Number: Petition for Certificate of Rehabilitation and Pardon Penal Code 4852.01 Page 5 of 7 (D) Penal Code 1203.4 History (For Probationers Only) A. After termination of probation on , a petition for relief under Penal Code section 1203.4 was gr