Rev. 2019
Notice of Intent to Apply, Page 1 of 1
Governor Gavin Newsom · State Capitol ·Sacramento, California 95814
You must send notice of your intent to apply for clemency (commutation of sentence or pardon) to the district attorney
when you apply. Complete and mail this form to the district attorney in the county/counties of your conviction(s) for
which you are seeking a commutation or pardon when you submit your application for clemency to the Governor’s
To the District Attorney of __________________ County: Please take notice that I, _______________________,
(Name of County) (Print Full Name of Applicant)
was convicted of ____________________________________________ on the date of ___________________________,
(Name of Crime) (Date of Conviction)
committed in __________________________ County, California.
(Name of County)
I will submit this application for (check one) commutation pardon to the Governor of the State of California.
_________________________________________ ___________________________________________
Applicant Signature Date
This section to be completed by the District Attorney only.
I, ____________________________________, District Attorney of the County of _________________________,
(Name of District Attorney) (Name of County)
do hereby acknowledge receipt of notice from _______________________________________, that applicant intends to
(Name of Applicant)
apply to the Governor of the State of California for clemency.
Signed ____________________________________
Date _____________________________________
District Attorney:
Please return this Notice to the Governor’s Office, Attn: Legal Affairs, Clemency, State Capitol, Sacramento, CA 95814.
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