FOR COURT OR BOARD OF PAROLE Docket, File or other Identifier STATE OF NEW YORK CERTIFICATE OF RELIEF FROM DISABILITIES This certificate is issued to the holder from all or certain enumerated disabilities, forfeitures, or bars to his employment automatically imposed by law by reason of his conviction of the crime or of the offense specified herein. This certificate shall NOT be deemed nor constructed to be a pardon. See reverse side for explanation of the law governing this certificate, or http://courts.state.ny.us/courts/10jd/suffolk/dist/RCD.shtml The original certificate is to be presented to the person to whom awarded. One copy is to be retained by the issuing agency, and one copy is to be filed with the NYS Division of Criminal Justice Services, 4 Tower Place, Albany, NY 12203-3702 1. Used by DCJS 3. Holder of Certificate 2. NYSID Last Name, First Name, Initial ( if unknow n, supp ly fingerprints to DCJS. If fingerprints are unobtainable, complete 15-18 below) 4. Crime or Offense for which convicted 7. Court of Disposition (Court, Part, Term, Venue) 9. 5. Date this certificate issued 6. Date of sentence 8. 10. Date of arrest Certificate issued by: “ Court indicated in box 7 “ State Board of Parole “ Certificate replaces an existing Certificate of Relief from Disabilities, previously issued on: “ Not applicable 11. This certificate shall “ 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 hereinafter enumerated 12. “ “ This certificate shall be considered permanent. This certificate shall be considered temporary until . After this date, unless revoked earlier by issuing court or parole board, this certificate shall be considered permanent. A person who knowingly uses or attempts to use a revoked certificate in order to obtain or exercise any right or privilege that he/she would not be entitled to obtain or to exercise without valid certificate shall be guilty of a misdemeanor. 13. 14. Signature of issuing official 15. Sex “ Male “ Female 16. Race Name of issuing official 17. Height Ft DC- DPCA-53 (6/05) Proposed Certificate submitted with DC- DPCA-52 title of issuing official 18. Date of Birth (Month/Day/Year) In. original copy to file copy to DCJS American LegalNet, Inc. www.FormsWorkflow.com