Fillable Form 1: [Your Name] [Your address, telephone and (California)

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Form 1: [Your Name] [Your address, telephone and (California)

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[Your Name]
[Your address, telephone and fax numbers]
Petitioner In Propria Persona
California Superior Court, ________________County
People of California,
)
Case No.: [Case number]
)
Plaintiff,
)
Petition by [your name]
)
Requesting Finding of Factual
vs.
)
Innocence and Issuance of
)
Certificate of Identity Theft
[Defendant’s name as it appears
)
)
[Penal Code §§ 530.6 & 851.8,
in Court records],
)
California Rule of Court 4.601]
)
Defendant
1. I, the Petitioner [insert your name] reasonably believe
that I am a victim of the crime of identity theft.
2. Based on the facts set forth below, I request:
a. A finding of factual innocence (Penal Code, §§ 530.6 and
851.8), and
b. Issuance of a Certificate of Identity Theft: Judicial
Finding of Factual Innocence. (California Rule of Court
4.601.)
Petition Seeking Certificate of Identity Theft - Page 1
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____________________________________________________
3. If available, a copy of the report of the suspected crime of
identity theft relating to my identity will be presented to the
judge at the hearing of this petition. It is not attached here
in order to protect the confidentiality of the personal
information contained in that document.
4. The following circumstances support this Petition:
[To Petitioner: Check boxes that apply to your circumstances and fill in
corresponding blanks. Fully describe documents and bring originals or true
and correct copies of the documents (certified if possible) to all hearings.]
a. An identity thief was cited in my name. I was not the
person cited.
Date of citation: ___________________________
Violation of Law Stated in Citation:_________________
Citation Number: ____________________________
Name and Address of Agency that Issued the Citation:
The original citation (or a true and correct copy of the
citation), if in my possession, will be presented to the
judge at the hearing of this petition. It is not attached
here in order to protect the confidentiality of the
personal information contained in that document.
Petition Seeking Certificate of Identity Theft - Page 2
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____________________________________________________
___________________________________________________
___________________________________________________________
_____________________________________________________
b. An identity thief was arrested, in my name. I am not the
person arrested.
Date of arrest: ____________
Name and Address of Arresting Agency: _____________
Arrest Warrant Number: _______________
Name and Address of Agency that Issued the Warrant:
A true and correct copy of the warrant, if in my
possession, will be presented to the judge at the hearing
of this petition. It is not attached here in order to
protect the confidentiality of the personal information
contained in that document.
c. An identity thief was convicted in my name of a crime.
am not the person convicted.
Date of conviction: ____________
Crime involved
(include section of law if known):
Name and address of Court: __________________________
Case Number: _______________
A certified copy of the Judgment of conviction will be
presented to the judge at the hearing of this petition. It
Petition Seeking Certificate of Identity Theft - Page 3
I
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_____________________________________________________
______________________________________________________
is not attached here in order to protect the
confidentiality of the personal information contained in
that document.
d. A criminal complaint has been filed against an identity
thief in my name. I am not the person named in the
complaint:
Name and address of Court: __________________________
Case Number: _______________
Date Complaint was filed: _____________________
A certified copy of the Complaint will be presented to the
judge at the hearing of this petition. It is not attached
here in order to protect the confidentiality of the personal
information contained in that document.
e. My identity has been mistakenly associated with a record
of criminal conviction. I am not the person named in the
record.
Date of conviction: __________
Name and address of Court: __________________________
Crime involved
[include section of law if known]: _________
Petition Seeking Certificate of Identity Theft - Page 4
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____________________________________________________
__________________
A true and correct copy of the record of criminal
conviction, if in my possession, will be presented to the
judge at the hearing of this petition. It is not attached
here in order to protect the confidentiality of the
personal information contained in that document.
f. I was arrested for a crime committed by an identity thief
using my name. I did not commit the crime.
Date of Arrest: __________
Name and Address of Arresting Agency:
Arrest Warrant Number: _______________
Agency that Issued the Warrant: _______________
A copy of the warrant, if in my possession, will be
presented to the judge at the hearing of this petition. It
is not attached here in order to protect the
confidentiality of the personal information contained in
that document.
Date I served the petition (required by Penal Code section
851.8) on the arresting agency: ____________
Date I served that petition on the district attorney:
Date that petition was denied: ____________________
Petition Seeking Certificate of Identity Theft - Page 5
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A true and correct copy of the petition required by Penal
Code section 851.8 (including any attachments) will be
presented to the judge at the hearing of this petition. It
is not attached here in order to protect the
confidentiality of the personal information contained in
the document.
5. There is no reasonable cause to believe that I committed the
offense for which he identity thief was arrested, cited,
convicted, or was the actual subject of a criminal complaint in
my name; or there is no reasonable cause to believe that my
identity has not been mistakenly associated with a record of
criminal conviction.
6. I will provide, to the judge, my basic personal
identification information, such as my full name, date of birth,
gender, weight, height, natural hair color, natural eye color,
race, and age, as well as my driver’s license, identification
card, and passport (if available). However, such information is
not included in this Petition in order to protect the
confidentiality of that information.
7. The following additional facts and/or described documents
support this Petition: _____________________________________
(If necessary, attach a separate page marked “Attachment to Petition by [your
name] Seeking Certificate of Identity Theft, Supporting Paragraph Number 6”.)
Petition Seeking Certificate of Identity Theft - Page 6
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I declare under penalty of perjury under the laws of the state
of California that the foregoing is true and correct.
Dated this: [Date] _____________________
[Your name]
Petition Seeking Certificate of Identity Theft - Page 7
ATTORNEY OR PARTY WITHOUT ATTORNEY (Name and Address):
TELEPHONE NO.:
ATTORNEY FOR (Name):
FOR COURT USE ONLY
NAME OF COURT:
STREET ADDRESS:
MAILING ADDRESS:
CITY AND ZIP CODE:
BRANCH NAME:
PLAINTIFF/PETITIONER:
DEFENDANT/RESPONDENT:
DECLARATION
CASE NUMBER:
I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct.
Date:
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
(TYPE OR PRINT NAME) (SIGNATURE OF DECLARANT)
Petitioner/Plaintiff Respondent/Defendant Attorney
Other (specify):
(See reverse for a form to be used if this declaration will be attached to another court form before filing)
Form Approved by the
Judicial Council of California
DECLARATION
MC-030 [New January 1, 1987]
WEST GROUP
Official Publisher
PLAINTIFF/PETITIONER:
DEFENDANT/RESPONDENT:
This form must be attached to another form or court paper before it can be filed in court.
CASE NUMBER:
I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct.
Date:
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
(TYPE OR PRINT NAME) (SIGNATURE OF DECLARANT)
Petitioner/Plaintiff Attorney
Respondent/Defendant
Other (Specify):
(See reverse for a form to be used if this declaration is not to be attached to another court paper before filing)
Form Approved by the
Judicial Council of California
ATTACHED DECLARATION
MC-031 [New January 1, 1987]
WEST GROUP
Official Publisher
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[Your Name]
[Your address, telephone and fax numbers]
Petitioner In Propria Persona
California Superior Court, ________________County
People of California,
)
Case No.: [Case number]
)
Plaintiff,
)
)
vs.
)
Proof of Service
)
[Defendant’s name as it appears
)
)
in Court records],
)
)
Defendant
1. I am 18 years of age or over and not a party to this action.
2. I personally delivered to the person identified in section 4,
below, a copy of all documents checked below:
a. ? Petition by [your name] Requesting Finding of Factual
Innocence and Issuance of Certificate of Identity Theft
b. ? Declaration of ___________________
c. ? Other
(specify): _________________________
3. I gave copies of the documents checked in section 2, above,
to the person identified in section 4, below, on:
a. Date: _________________
b. Time: _________________ ? a.m. ? p.m.
Proof of Service - Page 1
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____________________________
c. At this address: ___________________________________
4. Identity of person to whom documents checked in section 2,
above, were delivered:
Name:________________________
Position/Title:____________________
5. Identity of the Person who served the documents checked in
section 2, above:
Name: ______________________
Address: ________________________________________________
Telephone: __________________________
(If you are a process server):
County of registration: _________________
Registration number: ________________
I declare under penalty of perjury under the laws of the State
of California that the information above is true and correct.
Date: _________________ _______________________
[process server signs above]
[print process server’s name]
Proof of Service - Page 2
CONFIDENTIAL (SEE RULE 4.601)
CR-150
ATTORNEY OR PARTY WITHOUT ATTORNEY (Name, state bar number, and address):
ATTORNEY FOR (Name):
TELEPHONE NO. (Optional): FAX NO. (Optional):
E–MAIL ADDRESS (Optional):
FOR COURT USE ONLY
PEOPLE OF THE STATE OF CALIFORNIA
vs.
DEFENDANT:
CERTIFICATE OF IDENTITY THEFT: JUDICIAL
FINDING OF FACTUAL INNOCENCE
(Penal Code § 530.6)
CASE NUMBERS:
Warrant No. (if any):
Violation Date:
1.
Name:
Petitioner Information:
Booking No.:
MSex: F
Ht.:
Driver's License or Identification No.:
Eye Color:
Hair Color:Wt.:
Date of Birth:
Race:
Age:
Other Identifying Information:
2.
The court finds that:
Another person was arrested for or convicted of a crime under the identity of the petitioner in this case.
The petitioner's identity has been mistakenly associated with a record of the criminal conviction in this case.
The petitioner is not the person for whom the warrant in this case was issued.
Accordingly, the court finds that the petition is meritorious and that there is no reasonable cause to believe that the
petitioner committed the offense in this case, and that the petitioner is factually innocent of that offense.
Date:
JUDICIAL OFFICER
CERTIFICATION
1. The box to the right contains the petitioner's
I certify that this document is a
right thumbprint
correct copy of the original on file in
other print (specify):
my office.
(SEAL)
Date:
2. The print was taken on (date):
Clerk, by
3. The print was taken by
a. Name:
(DEPUTY)
b. Position:
c. Badge or serial No.:
ANY ALTERATION RENDERS THIS FORM VOID.
CONFIDENTIAL (SEE RULE 4.601)
Page 1 of 1
Form Adopted for Mandatory Use
Penal Code, § 530.6
CERTIFICATE OF IDENTITY THEFT: JUDICIAL
Judicial Council of California
CR-150 [New January 1, 2002]
FINDING OF FACTUAL INNOCENCE
IDENTITY THEFT:
Application for Registration as Victim
Complete form carefully and completely. Type or print neatly. All information is mandatory unless noted otherwise. If you
have any questions, please call toll free: 1 (888) 880-0240.
1. FULL NAME AND MAILING ADDRESS 2. RETURN TO:
CALIFORNIA DEPARTMENT OF JUSTICE
P.O. BOX 903417
SACRAMENTO CA 94203-4170
ATT: IDENTITY THEFT REGISTRY (G-210)
3. FINGERPRINTING
9LiveScan S Date Printed ____________ 910-Print Card Enclosed
4. MAIDEN NAME/ALIASES
5. SEX
9M 9F
6. BIRTH DATE 7. HEIGHT 8. WEIGHT 9. EYES 10. HAIR
11. BIRTHPLACE 12. SOCIAL SECURITY NUMBER (OPTIONAL) 13. DRIVER LICENSE NUMBER
14. ORDER PURSUANT TO SEC. 530.5(c) P.C.
9Yes 9No Court Name / Location Date
15. ORDER PURSUANT TO SEC. 530.6(b) P.C.
9Yes 9No Court Name / Location Date
16. ORDER OF FACTUAL INNOCENCE–CASE NO.
9Yes 9No Court Name / Location Date
I certify that the information given here is true and accurate and provided to facilitate my entry in the Identity Theft Victim Registry
maintained by the California Department of Justice as outlined in California Penal Code section 530.7
17. SIGNATURE 18. DATE
19. HOME PHONE
( )
20. WORK PHONE
( )
21. PASSWORD
.222222222-
22. QUESTION/ANSWER KNOWN ONLY TO YOU:
23. DESIGNATED RELEASE AUTHORIZATIONS
Authorization #1 Authorization #2
NAME OF COMPANY OR INDIVIDUAL NAME OF COMPANY OR INDIVIDUAL
STREET ADDRESS OR PO BOX STREET ADDRESS OR PO BOX
CITY, STATE, ZIP CITY, STATE, ZIP
CONTACT PERSON PHONE CONTACT PERSON PHONE
Authorization #3 Authorization #4
NAME OF COMPANY OR INDIVIDUAL NAME OF COMPANY OR INDIVIDUAL
STREET ADDRESS OR PO BOX STREET ADDRESS OR PO BOX
CITY, STATE, ZIP CITY, STATE, ZIP
CONTACT PERSON PHONE CONTACT PERSON PHONE
DOJ USE
ONLY:
ENTRY DATE/
INITIALS
VERIFICATION
DATE/INITIALS
r 04/26/2001
Clear Form
GUIDELINES FOR COMPLETING
IDENTITY THEFT: APPLICATION FOR REGISTRATION AS VICTIM
FORM
***
1. FULL NAME AND MAILING ADDRESS: If already filled in by DOJ, proofread this
box carefully and make any corrections. “NMI” means “No Middle Name”.
2. RETURN TO: Already completed by DOJ. Mail completed packet to this address.
3. FINGERPRINTING: If you are fingerprinted electronically at a LiveScan site, they will
send the information directly to DOJ. Check the “LiveScan” box and write in the date that
you were printed. If you are unable to go to a LiveScan site and must be fingerprinted in
ink, you must attach the card to this form and check the “10-Print Card Enclosed” box.
4. MAIDEN NAME/ALIASES: Please list all names you have used. This includes
Maiden Name, former married names, etc.
5. SEX: Check box for Male (M) or Female (F).
6. BIRTHDATE: Month, Day, Year of your birth.
7. HEIGHT: Height in feet and inches to nearest inch.
8. WEIGHT: Weight in pounds to nearest whole number.
9. EYES: Color of eyes.
10. HAIR: Color of hair.
11. BIRTHPLACE: If born in the United States, Mexico, or Canada, write in the name of
the state or province. If born in a country other than the United States, Mexico, or Canada,
write in the name of the country only.
12. SOCIAL SECURITY NUMBER: (Optional)
13. DRIVER LICENSE NUMBER: California Driver License or DMV-issued
identification, or Military Driver License.
14. ORDER PURSUANT TO SECTION 530.5(C) PC: If you have obtained a court order
under this Penal Code section, check the “Yes” box and write in the name of the court and
the date of the order. If you have not obtained a court order under this Penal Code section,
check the “No” box.
15. ORDER PURSUANT TO SECTION 530.6 (B) PC: If you have obtained a court order
under this Penal Code Section, check the “Yes” box and write in the name of the court and
the date of the order. If you have not obtained a court order under this Penal Code section,
check the “No” box.
16. ORDER OF FACTUAL INNOCENCE PURSUANT TO SECTION 851.8 PC: If you
have obtained an Order of Factual Innocence, check the “Yes” box and write in the name
of the court and the date of the order. If you have not obtained a court order under this
Penal Code section, check the “No” box.
17. SIGNATURE: Your signature.
18. DATE: Date you completed and sent in this form.
19. HOME PHONE: Your home phone number including Area Code.
20. WORK PHONE: (Optional) Your work phone number including Area Code.
21. PASSWORD: Password you create to identify you when you contact DOJ in the future
to change information or add Designated Release Authorizations. You must use at least
six and no more than ten characters - letters and numbers, capitals and lower case. No
spaces or special characters (!@#$%&*+) are allowed.
22. QUESTION/ANSWER KNOWN ONLY TO YOU: Additional verification for DOJ to
identify you. You must create a short (no more than 45 characters) question and answer
that should only be known to you. For example: “What is my favorite hobby?” -
“Snowboarding” or “What is my favorite movie?” - “BackDraft”.
23. DESIGNATED RELEASE AUTHORIZATIONS: Any company or individual that
you designate and authorize the DOJ to verify your registration status as a victim of
identity theft in the DOJ data base. DOJ will mail certified letters to you and your
designees once you are registered. If you wish to make any changes to your personal data
or your designated release authorizations, you may do so at any time by calling or writing
to the DOJ. Designees may call to verify your status at any time.
REQUEST FOR LIVE SCAN SERVICE
Applicant Submission
ORI: Type of Application:
(check one) Employment License, Certification, Permit Volunteer
Code assigned by DOJ
Job Title or Type of License, Certification or Permit:
Agency Address Set Contributing Agency:
Agency authorized to receive criminal history information Mail Code (five-digit code assigned by DOJ)
Street No. Street or PO Box Contact Name (Mandatory for all school submissions)
( )
City State Zip Code Contact Telephone No.
Name of Applicant:
(Please print) Last First MI
AKA’s:
CDL No.
Last First
DOB:
SEX: Male Female Misc. No. BIL -
Agency Billing Number (if applicable)
HT:
WT: Misc. No.
EYE Color: HAIR Color: Home Address:
(Applies only if Youth Org/HRA or Public Utility submission)
POB: Street or PO Box
SOC: City, State and Zip Code
Your Number:
OCA No. (Agency Identifying No.)
Level of Service DOJ FBI
If resubmission, list Original ATI No.
Employer:
(Additional response for Department of Social Services, DMV/CHP licensing, and Department of Corporations submissions only)
Employer Name
Street No.
Street or PO Box Mail Code (five digit code assigned by DOJ)
( )
City
State Zip Code Agency Telephone No. (Optional)
Live Scan Transaction Completed By:
Date
Name of Operator
Transmitting Agency
ATI No. Amount Collected/Billed
BCII 8016 (Rev10/98)
ORIGINAL-Live Scan Operator; SECOND COPY-Requesting Agency; THIRD COPY-Applicant
CA0349412
VICTIM OF IDENTITY THEFT
X
DEPARTMENT OF JUSTICE
SACRAMENTO CA 94203 - 4170
P.O. BOX 903417
06168
COMMAND CENTER
916
227 - 3244
N/A
N/A
N/A
X
NONE
GUIDELINES FOR COMPLETING
REQUEST FOR LIVE SCAN SERVICE APPLICANT SUBMISSION FORM
***
NAME OF APPLICANT: Enter applicant’s full name.
AKA’S: Names (if any) the applicant has used. CDL NO: California Driver’s
License Number
DOB: Date of Birth SEX: Gender (male or female) MISC. NO. BIL: COMPLETED
BY DOJ.
HT: Height WT: Weight MISC. NO.: Enter other identifying
numbers (e.g. Other State Driver’s
License Number)
EYE COLOR: Eye Color HAIR COLOR: Hair Color HOME ADDRESS: Home Address
POB: Place of Birth
SOC: Social Security Number (optional)
THE LIVE SCAN OPERATOR WILL COMPLETE THE BOTTOM OF THE FORM AND
COMPLETE THE FINGERPRINT PROCESSING. THE OPERATOR WILL KEEP THE
ORIGINAL COPY OF THIS FORM AND GIVE THE APPLICANT THE SECOND AND
THIRD COPIES. THE APPLICANT WILL RETAIN THE THIRD COPY FOR THEIR
PERSONAL RECORDS.
IT IS IMPORTANT THAT THE APPLICANT INCLUDE THE SECOND COPY OF
THIS REQUEST FORM WITH THE OTHER REQUIRED/COMPLETED
DOCUMENTS OF THE APPLICANT PACKET WHEN MAILING TO THE
DEPARTMENT OF JUSTICE.
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Form 1: Your Name Your address, telephone and (California)

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Completed 19 May 2022

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