Madera — Petition for Certificate of Rehabilitation and Pardon (Penal Code 4852.01 et seq.) (MAD-CRM-010)

Source: https://www.madera.courts.ca.gov/system/files/forms-and-filings/mad-crm-010-petition-certificate-rehabilitation-and-pardon-pursuant-penal-code-ssss485201-485206-rev.pdf

MAD-CRM-010 IN THE SUPERIOR COURT OF THE STATE OF CALIFORNIA IN AND FOR THE COUNTY OF MADERA

FOR COURT USE ONLY

In the Matter of the Application of

Type Applicant’s Full Name – First, Middle, Last, and Suffix

Date of Birth:

CII Number:

Criminal Case Number: List all applicable Criminal Numbers

PETITION FOR CERTIFICATE OF REHABILITATION AND PARDON Pursuant to Penal Code §§4852.01, 4852.06

The above-named applicant hereby respectfully represents and shows that: FELONY HISTORY

[ All felony convictions must be listed. If you have suffered more than three (3) felony convictions, attach additional sheets following the same format. ] Most Recent Felony Conviction

On or about , I was convicted of the crime of Month Day. Year Indicate crime and Penal Code Section

In the County of , California. My sentence for this offense was
[ Check all that apply ]
Commitment to state prison or other state institution at
Name of institution or city where located

Probation with suspended sentence to state prison or other state institution;

Probation, after the sentencing proceedings were suspended.

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

Discharged from state prison or other state institution after completing my sentence;

Released on parole, from which I was finally discharged on
Discharge date
Released from custody on probation after serving a jail sentence;

As a condition of my probation, I was released from custody after serving time in jail, and successfully

completed my probation on , and obtained relief under Penal Code
Date probation ended
section 1203.4 on .
Date 1203.4 granted by the court

Felony conviction was reduced to a misdemeanor (Provide court information):

Form Adopted for Optional Use PETITION FOR CERTIFICATE OF REHABILITATION AND PARDON Page １ of 3 Madera Superior Court Local Form Pursuant to Penal Code §§4852.01, 4852.06MAD-CRM-010 [Rev. 04/15/2020]

MAD-CRM-010 Second Most Recent Felony Conviction

On or about , I was convicted of the crime of Month Day. Year Indicate crime and Penal Code Section

In the County of , California. My sentence for this offense was
[ Check all that apply ]
Commitment to state prison or other state institution at
Name of institution or city where located

Probation with suspended sentence to state prison or other state institution;

Probation, after the sentencing proceedings were suspended.

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

Discharged from state prison or other state institution after completing my sentence;

Released on parole, from which I was finally discharged on
Discharge date
Released from custody on probation after serving a jail sentence;

As a condition of my probation, I was released from custody after serving time in jail, and successfully

completed my probation on , and obtained relief under Penal Code
Date probation ended
section 1203.4 on .
Date 1203.4 granted by the court

Felony conviction was reduced to a misdemeanor (Provide court information):

Third Most Recent Felony Conviction

On or about , I was convicted of the crime of Month Day. Year Indicate crime and Penal Code Section

In the County of , California. My sentence for this offense was
[ Check all that apply ]
Commitment to state prison or other state institution at
Name of institution or city where located

Probation with suspended sentence to state prison or other state institution;

Probation, after the sentencing proceedings were suspended.

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

Discharged from state prison or other state institution after completing my sentence;

Released on parole, from which I was finally discharged on Discharge date Released from custody on probation after serving a jail sentence;

As a condition of my probation, I was released from custody after serving time in jail, and successfully

completed my probation on , and obtained relief under Penal Code
Date probation ended
section 1203.4 on .
Date 1203.4 granted by the court

Felony conviction was reduced to a misdemeanor (Provide court information):

Form Adopted for Optional Use PETITION FOR CERTIFICATE OF REHABILITATION AND PARDON Page ２ of 3 Madera Superior Court Local Form Pursuant to Penal Code §§4852.01, 4852.06MAD-CRM-010 [Rev. 04/15/2020]

MAD-CRM-010 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. Month Day, Year

APPLICANT’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. (Pen. Code, § 4852.05.)

WHEREFORE, your petitioner prays that the Court make its order and decree declaring that the petitioner has been rehabilitated; and for a certificate of rehabilitation recommending that the Governor of the State of California grant the petitioner a full pardon; and that for such purpose, a time be appointed for the hearing of the foregoing petition; and that other and necessary proper orders may be made in the premises.

SIGN

Applicant’s Signature Month Day, Year

Applicant’s Street Address

Applicant’s City, State and Zip Code

Applicant’s Driver’s License Number

Applicant’s Email Address

Applicant’s Home Phone Number

Applicant’s Work Phone Number

Applicant’s Cell Phone Number

Form Adopted for Optional Use PETITION FOR CERTIFICATE OF REHABILITATION AND PARDON Page ３ of 3 Madera Superior Court Local Form Pursuant to Penal Code §§4852.01, 4852.06MAD-CRM-010 [Rev. 04/15/2020]