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: Criminal Case Number(s): PETITION FOR CERTIFICATE OF REHABILITATION AND PARDON (Penal Code 4852.01 et seq.) To the Superior Court of California, County of Orange: The above-named petitioner represents and shows that: CONVICTION HISTORY CASE NUMBER: M- [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 on case number: Month Day, Year , petitioner was convicted of the crime of in the County of , California. Indicate Crime and Code Section (B) Type of Sentence or Disposition Petitioner's sentence for this offense was: [Check the appropriate box] Commitment to state prison or other state institution at Sentenced to county jail pursuant to Penal Code 1170(h) at Name of institution or city where located 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. L-0408 Revised: 12/31/2015 Petition for Certificate of Rehabilitation and Pardon Page 1 of 7 Penal Code 4852.01 American LegalNet, Inc. www.FormsWorkFlow.com Name: Case Number: M(C) Date of Release Thereafter, on or about Date released from custody , petitioner was; [Check the appropriate box(es)] Discharged from state prison or other state institution after completing his/her sentence on Released on parole on (date). (date). (date). (date). (date). Released from county jail pursuant to Penal Code 1170(h) (no mandatory supervision) on Released from county jail to serve mandatory supervision pursuant to Penal Code 1170(h) on Released from custody on probation (after serving a jail sentence as a condition of probation) on 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. C. 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 If yes, when and where? . No D. Is petitioner currently on probation or mandatory supervision for the commission of any other felony? Yes 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/her Penal Code section 1203.41 petition was granted? Yes_____ No_____ c) If yes, when and where? _______________________________. d) Is petitioner currently on probation 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): L-0408 Revised: 12/31/2015 Petition for Certificate of Rehabilitation and Pardon Page 2 of 7 Penal Code 4852.01 American LegalNet, Inc. www.FormsWorkFlow.com Name: Case Number: MSecond Most Recent Qualifying Conviction (A) Offense On or about on case number: Month Day, Year , petitioner was convicted of the crime of , California. Indicate Crime and Code Section in the County of (B) Type of Sentence or Disposition Petitioner's sentence for this offense was: [Check the appropriate box] Commitment to state prison or other state institution at Sentenced to county jail pursuant to Penal Code 1170(h) at Name of institution or city where located 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 [Check the appropriate box(es)] Discharged from state prison or other state institution after completing his/her sentence on Released on parole on (date). (date). , petitioner was; Date released from custody 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). (date). Released on probation (if no jail sentence was imposed) on (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. C. 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_ If yes, when and where? D. Is petitioner currently on probation or mandatory supervision for the commission of any other felony? Yes E. No 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): L-0408 Revised: 12/31/2015 Petition for Certificate of Rehabilitation and Pardon Page 3 of 7 Penal Code 4852.01 American LegalNet, Inc. www.FormsWorkFlow.com Name: Case Number: M(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/her Penal Code section 1203.41 petition was granted? Yes_____ No_____ c) If yes, when and where? _______________________________. d) Is petitio