ATTORNEY OR PARTY WITHOUT ATTORNEY (Name & Address): FOR COURT USE ONLY Telephone No.: E-Mail Address (Optional): ATTORNEY FOR (Name): Fax No. (Optional): Bar No: SUPERIOR COURT OF CALIFORNIA, COUNTY OF ORANGE CENTRAL JUSTICE CENTER 700 CIVIC CENTER DRIVE WEST POST OFFICE BOX 22024 SANTA ANA, CA 92702-2024 In the Matter of the Application of ________________________________________________________________ Type Petitioner's full name ­ First Middle Last and Suffix, if applicable Date of Birth: CII Number: NOTICE OF FILING OF PETITION FOR CERTIFICATE OF REHABILITATION AND PARDON (Penal Code § 4852.07) To the Governor of the State of California: To the District Attorney, County of To the District Attorney, County of To the District Attorney, County of To the District Attorney, County of County of Petitioner's Residence M- CASE NUMBER: ; ; ; ; County of most recent qualifying conviction, if different from County of Residence County of 2nd most recent qualifying conviction, if applicable County of 3rd most recent qualifying conviction, if applicable On _________________________ the undersigned has filed a petition in the above mentioned court for a Date of Filing Certificate of Rehabilitation and Pardon in accordance with the provision of Chapter 3.5, Title 6, Part 3 of the Penal Code of the State of California. The petition will be heard on _______________ at ___________ in Department __________ at the Superior Court Date of Hearing Time Department of California, County of Orange, Central Justice Center. Date SIGNATURE OF PETITIONER TYPE OR PRINT NAME OF PETITIONER Petitioner's Address: City, State, ZIP NOTICE OF FILING OF PETITION FOR CERTIFICATE OF REHABILIATION AND PARDON Optional Use Form: L-409 [Rev.July 15, 2011] Penal Code, §§ 4852.07 American LegalNet, Inc. www.FormsWorkFlow.com