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IN THE SUPERIOR COURT OF THE STATE OF (Sacramento County Public Law Library)

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IN THE SUPERIOR COURT OF THE STATE OF CALIFORNIA
IN AND FOR THE COUNTY OF
Applicant's County of Residence
In the Matter of the Application of
Court use only
Type Applicant’s Full Name - First Middle Last and Suffix, if applicable
Date of Birth
Month Day, Year
CII Number
Criminal Case Number(s)
List applicable Criminal Case Number(s)
PETITION FOR CERTIFICATE OF REHABILITATION AND PARDON
Pursuant to Penal Code Sections 4852.01 and 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 appropriate box ]
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
[ Check appropriate box ]
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
FORM 1 (Revised 1/21/98) This form was prepared by the Investigations Division of the Board of Prison Terms pursuant to Penal Code Section 4852.18.
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 appropriate box ]
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
[ Check appropriate box ]
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
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 appropriate box ]
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
[ Check appropriate box ]
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
FORM 1 (Revised 1/21/98) This form was prepared by the Investigations Division of the Board of Prison Terms pursuant to Penal Code Section 4852.18.
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.
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 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.
Applicant's Signature Month Day, Year
Applicant's Street Address
Applicant's City, State ZIP Code
FORM 1 (Revised 1/21/98) This form was prepared by the Investigations Division of the Board of Prison Terms pursuant to Penal Code Section 4852.18.
FORM 1 INSTRUCTIONS
1. After completing the Petition for Certificate of Rehabilitation and Pardon, file it with the
County Clerk's office in the county in which you reside. In every case, you must have
resided continuously for five (5) years in this state prior to filing the petition.
2. The period of rehabilitation begins to run upon your discharge from custody or upon release
on parole or probation, whichever is sooner. The period of rehabilitation shall constitute
five (5) years residence in this state, plus a period of time determined by the following rules:
• To the five (5) years there shall be added four (4) years in the case of any person
convicted of violating Section 187, 209, 219, 4500, or 12310 of the penal code, or
subdivision (a) of Section 1672 of the Military and Veterans Code, or any other offense
which carries a life sentence.
• To the five (5) years there shall be added two (2) years in the case of any person
convicted of committing any offense not listed above and which does not carry a life
sentence. (The majority of applicants require a seven-year rehabilitation period).
• To the five (5) years the trial court hearing the application for the Certificate of
Rehabilitation may add additional years when a person has served consecutive
sentences. The amount of additional time will not exceed the sum of the maximum
penalties for all the crimes.
• Any person discharged after completion of his/her term or released on parole before
May 13, 1943, is not subject to the periods of rehabilitation set forth in these rules.
3. If you were released on felony probation and successfully completed probation, you must
obtain relief under Penal Code Section 1203.4 before applying for a Certificate of
Rehabilitation.
4. You are entitled to be represented by an attorney of your own selection, or by the public
defender. You are entitled to receive assistance from all rehabilitative agencies including
officers from adult probation and parole, and for persons under the age of 30 years, from the
Youth Authority.
5. It is unlawful for anyone, other than an attorney, to accept any fee, money or anything of
value for their services in representing you in this proceeding.
6. You are not required to pay filing fees of any kind in connection with this proceeding.
7. When the Court sets a hearing date on your Petition, you are required to give notice of that
date at least thirty (30) days before the hearing. You must formally notify the District
Attorney for each county in which you have been convicted, and the Governor's Office.
8. A Certificate of Rehabilitation is not an automatic pardon; it is only an automatic application
for a pardon.
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IN THE SUPERIOR COURT OF THE STATE OF (Sacramento County Public Law Library)

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Completed 29 March 2022

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