PETITION FOR APPROVAL OF THE RIGHT TO BE ELIGIBLE TO REGISTER TO VOTE COMMONWEALTH OF VIRGINIA To the Circuit Court of I, NAME OF PETITIONER Case No , hereby petition this court for approval of this petition seeking restoration of my eligibility to register to vote. In support of this petition, I state that the following information is true: 1. My current address and telephone number are: TELEPHONE NUMBER 2. The felony conviction(s) which led to the loss of my civil rights was (were) NAME AND CODE SECTION OF VIOLATION(S) , for which I was convicted on DATE in COURT ATTACHED ADDITIONAL SHEET(S) 3. As a result of the conviction(s), I received a sentence of of which I was placed on probation for 4. I am not currently on probation or parole, nor am I subject to any suspended sentence. 5. At least five years have passed since the completion of any sentence and any modification of sentence, including all periods of probation or parole and any suspension of sentence. 6. I have not been convicted of any criminal violation during the period set out in paragraph 5 above. I understand that this affirmation does not include convictions for traffic infractions. 7. I have demonstrated civic responsibility through the following community or comparable service: , was suspended. ATTACHED ADDITIONAL SHEET(S) In support of this petition, the following documents are attached: Based on the above, I petition this Court under Virginia Code § 53.1-231.2 for approval of my eligibility to register to vote. SIGNATURE OF PETITIONER DATE FORM CC-1403 (PAGE ONE OF ONE)11/00 PDF VA. CODE § 53.1-231.2 American LegalNet, Inc. www.USCourtForms.com