STATE OF ILLINOIS CIRCUIT COURT OF LAKE COUNTY CERTIFICATE OF RELIEF FROM DISABILITIES Pursuant to the provisions of 730 ILCS 5/5-5.5-15, this certificate is issued to the holder to grant relief from the disabilities enumerated herein. The original certificate shall be retained by the holder, a copy shall be retained by the court, and copies shall be filed with the Illinois Department of Professional Regulation and the Illinois State Police. Case Number: Holder of Certificate: Address: Street City State Zip Social Security #: Offense of Conviction: Date of Birth: Date of Sentence: This certificate shall relieve the holder of disabilities or bars to employment herein enumerated: Pursuant to the provisions of 730 ILCS 5/5-5.5-35, this certificate is deemed to be temporary and is subject to revocation for cause. This certificate does not guarantee the issuance of a license; the holder must comply with all requirements of the licensing agency. This certificate shall not be deemed or construed to be a pardon. Judge's Signature: Copies To: Department of Professional Regulation Licensing & Testing Division 320 W. Washington Street Springfield, IL 62786-0002 Date: Illinois State Police Bureau of Identification 260 N. Chicago Street Joliet, IL 60432 American LegalNet, Inc. www.USCourtForms.com