Application By Eligible Offender For Certificate Of Relief From Civil Disabilities
Download Free Print-Only PDF OR Purchase Interactive PDF Version of this Form
Application By Eligible Offender For Certificate Of Relief From Civil Disabilities Form. This is a New York form and can be use in General Statewide.
Loading PDF...
Tags: Application By Eligible Offender For Certificate Of Relief From Civil Disabilities, DPCA-52, New York Statewide, General
STATE OF NEW YORK
APPLICATION BY AN ELIGIBLE OFFENDER FOR
CERTIFICATE OF RELIEF FROM DISABILITIES
1.
Applicant's Last Name
2.
Address (Street and House Number, City, State, ZIP)
4.
Sex
FOR COURT OR BOARD OF PAROLE
Docket, File or other Identifier
5.
M ale
8.
First Name
Race
Initial
6.
Height
Female
Ft
Offense for which convicted
9.
11. Court of Disposition (Court, Part, Term, Venue)
3.
7.
NYSID (if known)
Date of Birth (Month/Day/Year)
In.
Date of arrest
10. Date of sentence
12. Certificate issued by:
Court indicated in box 11
State Board of Parole
13.
Certificate is intended to replace an existing certificate,
issued on:
Not applicable
14. Application is hereby made for a grant of a Certificate of Relief from Disabilities which will
a. relieve the holder of all forfeitures, and of all disabilities and bars to employm ent, excluding the right to retain
or to be eligible for public office, by virtue of the fact that the certificate is issued at the time of sentence.
b. relieve the holder of all disabilities and bars to employment, excluding the right to be eligible for public office.
c. relieve the holder of the forfeitures, disabilities or bars to employment hereinafter enumerated
15. The applicant agrees to allow an investigation to be made to determine his or her fitness for a certificate of relief
from disabilities, pursuant to Correction Law Article 23.
Applicant’s Signature
Date
sign in the presence of a notary
16.
State of New York )
County of _________ )
ss.:
____________________________________, being duly sworn, deposes and says that __he is the applicant named in
the within application; that __he has read the foregoing application and knows the contents thereof; that the same
is true to h____ own knowledge, except as to the matters therein stated to be alleged on information and belief,
and that as to those matters __he believes it to be true.
Sworn to before me this _____ day of _____________ 20___
_________________________________
Notary Public
affix stamp / seal
DC- DPCA-52 (6-05)
American LegalNet, Inc.
www.FormsWorkflow.com
