Amador — CRIM-502.1

Source: https://amador.courts.ca.gov/system/files/crim-5021_petitionforcertificateofrehabilitation.pdf

ATTORNEY OR PARTY WITHOUT ATTORNEY (Name & Address): FOR COURT USE ONLY

Telephone No.: Fax No. (Optional): E-Mail Address (Optional): ATTORNEY FOR (Name): Bar No:

SUPERIOR COURT OF CALIFORNIA, COUNTY OF AMADOR 500 ARGONAUT LANE Jackson, CA 95642

In the Matter of the Application of

Type Petitioner’s full name – First Middle Last and Suffix, if applicable

Date of Birth:
CII Number:
Criminal Case Number(s):

PETITION FOR CERTIFICATE OF REHABILITATION AND PARDON CASE NUMBER:
(Penal Code 4852.01 et seq.)

To the Superior Court of California, County of Amador:

The above-named petitioner represents and shows that:

CONVICTION HISTORY

[All qualifying convictions must be listed. If you have more than three (3) qualifying convictions, attach additional sheets following the same format.]

Most Recent Qualifying Conviction

(A)

Offense

On or about , petitioner was convicted of the crime of Month Day, Year Indicate Crime and Code Section

on case number: in the County of , California.

(B)

Type of Sentence or Disposition

Petitioner’s sentence for this offense was: [Check the appropriate box]

Commitment to state prison or other state institution at ;
Name of institution or city where located

Sentenced to county jail pursuant to Penal Code 1170(h) at ;
Name of county where located

Sentenced to state prison, but execution of sentence was suspended and petitioner was placed on probation.

Imposition of sentence was suspended and petitioner was placed on probation.

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Name: Case Number:

(C)

Date of Release

Thereafter, on or about , petitioner was; Date released from custody

[Check the appropriate box(es)]

Discharged from state prison or other state institution after completing his/her sentence on (date).

Released on parole on (date).
Released from county jail pursuant to Penal Code 1170(h) (no mandatory supervision) on (date).
Released from county jail to serve mandatory supervision pursuant to Penal Code 1170(h) on (date).

Released from custody on probation (after serving a jail sentence as a condition of probation) on (date).

Released on probation (if no jail sentence was imposed) on (date).

(D)
Penal Code 1203.4 History (For Probationers Only)
A. After termination of probation on , a petition for relief under Penal Code section 1203.4 was
granted on (date).

B. Has petitioner been incarcerated in any prison, jail, detention facility, or other penal institution or agency after
his/her Penal Code section 1203.4 petition was granted? Yes No

C. If yes, when and where?

D. Is petitioner currently on probation or mandatory supervision for the commission of any other felony? Yes No

E. Petitioner presents the following evidence that he/she has resided in California for the past five years (supporting
documentation may be attached as exhibits to the petition):

(E)
Penal Code 1203.41 History (For sentences pursuant to PC 1170(h) only)

a) A petition for relief under Penal Code section 1203.41 was granted on __________________(date).

b) Has petitioner been incarcerated in any prison, jail, detention facility, or other penal institution or agency after his/her
Penal Code section 1203.41 petition was granted? Yes_____ No_____

c) If yes, when and where? _______________________________.

d) Is petitioner currently on probation for the commission of any other felony? Yes_____ No_____

e) Petitioner presents the following evidence that he/she has resided in California for the past five years (supporting
documentation may be attached as exhibits to the petition):

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Name: Case Number:

Second Most Recent Qualifying Conviction

(A)

Offense

On or about , petitioner was convicted of the crime of Month Day, Year Indicate Crime and Code Section

on case number: in the County of , California.

(B)

Type of Sentence or Disposition

Petitioner’s sentence for this offense was: [Check the appropriate box]

Commitment to state prison or other state institution at ;
Name of institution or city where located

Sentenced to county jail pursuant to Penal Code 1170(h) at ;
Name of county where located

Sentenced to state prison, but execution of sentence was suspended and petitioner was placed on probation.

Imposition of sentence was suspended and petitioner was placed on probation.

(C)
Date of Release

Thereafter, on or about , petitioner was; Date released from custody

[Check the appropriate box(es)]

Discharged from state prison or other state institution after completing his/her sentence on (date).

Released on parole on (date).

Released from county jail pursuant to Penal Code 1170(h) (no mandatory supervision) on ________(date;

Released from county jail to serve mandatory supervision pursuant to Penal Code 1170(h) on ________(date;

Released from custody on probation (after serving a jail sentence as a condition of probation)

on (date).

Released on probation (if no jail sentence was imposed) on (date).

(D)
Penal Code 1203.4 History (For Probationers Only)
A. After termination of probation on _, a petition for relief under Penal Code section 1203.4 was
granted on (date).

B. Has petitioner been incarcerated in any prison, jail, detention facility, or other penal institution or agency after
his/her Penal Code section 1203.4 petition was granted? Yes ____ No ____

C. If yes, when and where?

D. Is petitioner currently on probation or mandatory supervision for the commission of any other felony?

Yes No

E. Petitioner presents the following evidence that he/she has resided in California for the past five years (supporting
documentation may be attached as exhibits to the petition):

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Name: Case Number:

(E)
Penal Code 1203.41 History (For sentences pursuant to PC 1170(h) only)

a) A petition for relief under Penal Code section 1203.41 was granted on __________________(date).

b) Has petitioner been incarcerated in any prison, jail, detention facility, or other penal institution or agency after his/her
Penal Code section 1203.41 petition was granted? Yes_____ No_____

c) If yes, when and where? _______________________________.

d) Is petitioner currently on probation for the commission of any other felony? Yes_____ No_____

e) Petitioner presents the following evidence that he/she has resided in California for the past five years (supporting
documentation may be attached as exhibits to the petition):

Third Most Recent Qualifying Conviction

(A)
Offense

On or about , petitioner was convicted of the crime of Month Day, Year Indicate Crime and Code Section

on case number: in the County of , California.

(B)

Type of Sentence or Disposition

Petitioner’s sentence for this offense was: [Check the appropriate box]

Commitment to state prison or other state institution at ;
Name of institution or city where located

Sentenced to county jail pursuant to Penal Code 1170(h) at ;
Name of county where located

Sentenced to state prison, but execution of sentence was suspended and petitioner was placed on probation.

Imposition of sentence was suspended and petitioner was placed on probation.

(C)
Date of Release

Thereafter, on or about , petitioner was; Date released from custody

[Check the appropriate box(es)]

Discharged from state prison or other state institution after completing his/her sentence on (date).

Released on parole on (date).

Released from county jail pursuant to Penal Code 1170(h) (no mandatory supervision) on _____________________(date;

Released from county jail to serve mandatory supervision pursuant to Penal Code 1170(h) on ________________(date;

Released from custody on probation (after serving a jail sentence as a condition of probation) on _____________(date).

Released on probation (if no jail sentence was imposed) on (date).

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Name: Case Number:

(D)
Penal Code 1203.4 History (For Probationers Only)

A. After termination of probation on _, a petition for relief under Penal Code section 1203.4 was
granted on (date).

B. Has petitioner been incarcerated in any prison, jail, detention facility, or other penal institution or agency after
his/her Penal Code section 1203.4 petition was granted? Yes ____ No ____

C. If yes, when and where?

D. Is petitioner currently on probation or mandatory supervision for the commission of any other felony? Yes ____ No _____

E. Petitioner presents the following evidence that he/she has resided in California for the past five years (supporting
documentation may be attached as exhibits to the petition):

F.

G.

H.

(E)
Penal Code 1203.41 History (For sentences pursuant to PC 1170(h) only)

A. A petition for relief under Penal Code section 1203.41 was granted on __________________(date).

B. Has petitioner been incarcerated in any prison, jail, detention facility, or other penal institution or agency after his/her

Penal Code section 1203.41 petition was granted? Yes_____ No_____
C. If yes, when and where? _______________________________________________________________________.

D. Is petitioner currently on probation for the commission of any other felony? Yes_____ No_____

E. Petitioner presents the following evidence that he/she has resided in California for the past five years (supporting

documentation may be attached as exhibits to the petition):

RESIDENCY HISTORY
I am now a resident of the State of California, and I have continuously resided in the State of California from _________________

__________________________________, to the present date.

I currently reside in the County of at the following address:

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Name: Case Number:

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Name: Case Number:

PETITIONER’S DECLARATION

During the period of my rehabilitation, I have lived an honest and upright life, conducted myself with sobriety and industry, and exhibited good moral character. I have conformed to and obeyed all the laws of the land.

I request that the Court make its order declaring that I have been rehabilitated; and for a Certificate of

Rehabilitation recommending that the Governor of the State of California grant me a full pardon.

I declare under penalty of perjury under the laws of the State of California that the foregoing information is true

and correct.

Date SIGNATURE OF PETITIONER

TYPE OR PRINT NAME OF PETITIONER

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