Madera Superior Court Form Adopted for Optional Use MAD-CRM-0010 (Rev. 3/11/19) PETITION FOR CERTIFICATE OF REHABILITATION AND PARDON (PC 2474852.01 et. Seq.) Page of 3 ATTORNEY OR PARTY WITHOUT ATTORNEY (Name, Address, Telephone No.) ATTORNEY FOR (Name): FOR COURT USE ONLY SUPERIOR COURT OF CALIFORNIA, COUNTY OF MADERA Madera - 200 South G Street, Madera, CA 93637 Traffic 226 200 South G Street, Madera, CA 93637 PEOPLE OF THE STATE OF CALIFORNIA VS. Defendant: In re the Application of : (Print or type your name legibly) For a Certificate of Rehabilitation and Pardon PETITION FOR CERTIFICATE OF REHABILITATION AND PARDON (PC 2474852.01 et. Seq.) Case Number: To the Honorable Superior Court of the State of California, in and for the County of Madera: The petition of hereby respectfully requests and shows that (Fill in your name) I. (Complete this paragraph only with respect to your most recent felony conviction) On or about , 20 , I was convicted of the felony of , in the County of , (State crime and code section if you know it) State of California. My sentence for this offense was (check appropriate box): commitment to state prison or other institution at . probation with a suspended sentence to state prison or other institution. Thereafter, on or about , 20 , I was (check appropriate box) : (Date of release from actual custody) discharged from state prison or other state institution after completing my sentence; released on parole, from which I was finally discharged on , 20 ; released from custody on probation or after serving a jail sentence as part of my probation, successfully completed my probat ion on , 20 , and obtained relief under Penal Code 2471203.4 on , 20 . American LegalNet, Inc. www.FormsWorkFlow.com Madera Superior Court Form Adopted for Optional Use MAD-CRM-0010 (Rev. 3/11/19) PETITION FOR CERTIFICATE OF REHABILITATION AND PARDON (PC 2474852.01 et. Seq.) Page of 3 Note 1 (Complete this section with respect to your second most recent felony conviction, if any.) On or about , 20 , I was convicted of the felony of , in the County of , (State crime and code section if you know it) State of California. My sentence for this offense was (check appropriate box): commitment to state prison or other institution at . probation with a suspended sentence to state prison or other institution. Thereafter, on or about , 20 , I was (check appropriate box) : (Date of release from actual custody) discharged from state prison or other state institution after completing my sentence; released on parole, from which I was finally discharged on , 20 ; released from custody on probation or after serving a jail sentence as part of my probation, successfully completed my probat ion on , 20 , and obtained relief under Penal Code 2471203.4 on , 20 . Note 2 (Complete this section with respect to your third most recent felony conviction, if any.) On or about , 20 , I was convicted of the felony of , in the County of , (State crime and code section if you know it) State of California. My sentence for this offense was (check appropriate box): commitment to state prison or other institution at . probation with a suspended sentence to state prison or other institution. Thereafter, on or about , 20 , I was (check appropriate box) : (Date of release from actual custody) discharged from state prison or other state institution after completing my sentence; released on parole, from which I was finally discharged on ,20 ; released from custody on probation or after serving a jail sentence as part of my probation, successfully completed my probat ion on , 20 , and obtained relief under Penal Code 2471203.4 on , 20 . (If you have suffered more than three felony convictions, attach additional sheet following same format used on paragraph 1.) II. I am now a resident of the State of California and I have continuously resided in the State of California from , 20 , to the present date. American LegalNet, Inc. www.FormsWorkFlow.com Madera Superior Court Form Adopted for Optional Use MAD-CRM-0010 (Rev. 3/11/19) PETITION FOR CERTIFICATE OF REHABILITATION AND PARDON (PC 2474852.01 et. Seq.) Page of 3 III. During the period of my rehabilitation, I have lived an honest and upright life, conducted myself with sobriety and industry, and exhibited good moral character; I have conformed to and obeyed all the laws of the land. WHEREFORE, your petitioner prays that the Court make its order and decree declaring that the petitioner has been rehabilitated, and for a Certificate of Rehabilitation recommending that the Governor of the State of California grant petitioner a full pardon; and that for such purpose a time be appointed for the hearing of the foregoing petition, and that all other and necessary and proper orders may be made in the premises. DATED: , 20 . Signature of Petitioner Residence Address American LegalNet, Inc. www.FormsWorkFlow.com