IN THE SUPERIOR COURT OF THE STATE OF CALIFORNIA IN AND FOR THE COUNTY OF Applicant's County of Residence In the Matter of the Application of Court use only Type Applicant’s Full Name - First Middle Last and Suffix, if applicable Certificate Number Date of Birth CII Number Criminal Case Number(s) Month Day, Year List applicable Criminal Case Number(s) CERTIFICATE OF REHABILITATION Pursuant to Penal Code Section 4852.13 The petition of at , presently residing Type Applicant’s Full Name - First Middle Last and Suffix, if applicable Type Applicant's Street Address, City, State, and ZIP Code , heretofore filed, praying for a Certificate of Rehabilitation pursuant to the provisions of Chapter 3.5, Title 6 of Part 3 of the Penal Code of the State of California, came on regularly for hearing on this of Day of the Month day and proof having been made to the Month, Year satisfaction of the Court that notice of the time of hearing has been regularly given as required by law; and from satisfactory proof taken at said hearing the Court finds that all allegations of said petition are true, and that the required period of rehabilitation has elapsed since petitioner's date of discharge from custody due to completion of the term to which the petitioner was sentenced, or upon the release on parole or probation on , that, where appropriate, petitioner has Month Day, Year obtained relief pursuant to Penal Code Section 1203.4, and that petitioner has demonstrated by the course of conduct his/her rehabilitation and fitness to exercise all the civil and political rights of citizenship (except as provided in Penal Code Section 4852.15); and that petitioner has been Total Number of Felony Convictions time(s) convicted of a felony; WHEREFORE, It Is Ordered, Adjudged, and Decreed, And this court does hereby order, adjudge, and decree the petitioner has been rehabilitated and is fit to exercise all the civil and political rights of citizenship (except as provided in Penal Code Section 4852.15), and by virtue thereof, this court recommends that the Governor of the State of California grant a full pardon to said petitioner. Done in open court this day of Day of the Month Judge of said Superior Court - TYPED or PRINTED FORM 3 (Revised 7/6/2005) . Month, Year Judge of said Superior Court - SIGNATURE This form was prepared by the Investigations Division of the Board of Parole Hearings pursuant to Penal Code Section 4852.18. American LegalNet, Inc. www.FormsWorkFlow.com