Fillable PARDON REQUEST - BACKGROUND INFORMATION FORM (New York)

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PARDON REQUEST - BACKGROUND INFORMATION FORM (New York)

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ANDREW
M. CUOMO
Governor
ANTHONY J.
ANNUCCI
Acting Commissioner
PARDON REQUEST - BACKGROUND INFORMATION
FORM
Please complete this form, to the best of your knowledge, and return to: NYS
Department of Corrections and Community
Supervision
Executive Clemency Bureau
The Harriman State Campus – Building 2
1220 Washington Avenue
Albany, NY 12226-2050
Full Name of Applicant:
Current Address:
Phone Number(s):
Alias:
Date of Birth: Social Security Number: - -
DIN # NYSID# FBI #
Alien Registration # (for immigration cases):
Provide details if any Immigration (ICE) proceedings are pending:
Legal History
To the best of your knowledge, please list all New York State convictions only (attach additional page or write on back with
additional details if necessary:
Conviction Offense
Court of Conviction
(Include County and/or City)
Date of Sentence
Sentence
Reason for Pardon Request (attach additional page or write on back with additional details if necessary):
Applicant’s Signature: Date:
The
Harriman
State
Campus,
Building 2,
1220 Washington Avenue, Albany,
New York 12226-2050
To:
Department of Taxation and Finance
W.A. Harriman State Campus
Albany, New York 12227
(518) 435-2913
I, , authorize the Department of Taxation and Finance (“Department”) to
disclose and discuss with the Executive Clemency Bureau and the Governor’s Office (Executive
Chamber), the following information, for the purpose of considering my application for Executive
clemency:
Whether my New York State income tax returns have been timely filed, including appropriate
extensions, for the prior four tax years.
Whether any enforcement action – including, but not limited to, issuance of a tax warrant, lien, or
judgment -- has been taken by the Department of Taxation and Finance against me and the
status of such action; whether any income tax bills are currently outstanding past the due date, or
whether any protests are currently filed by me and the status of any such protests.
I do not authorize the Executive Clemency Bureau to disclose, discuss, or share tax information
other than that specifically delineated above. I understand that the Executive Clemency Bureau in no
case will provide actual tax filings. I understand that the Clemency Bureau and the Executive
Chamber will not share any tax information with any outside person or entity.
I will commence no claim against the Executive Clemency Bureau if they disclose the delineated
information according to this release.
My Social Security Number is:
Signature Date
WHAT IS THE NEW LAW?
Beginning October 7th, 2017, eligible individuals convicted of an eligible oense may request to have their
records sealed if they have not been convicted of another crime for a period of 10 years from the day they
were sentenced or released from jail/prison (whichever is later).
WHO IS ELIGIBLE TO SEAL THEIR CONVICTIONS UNDER CRIMINAL PROCEDURE LAW §160.59?
You are eligible if you have been crime-free for at least 10 years since your conviction and/or release and
you have only two (2) convictions on your criminal record. If you have more than two (2) convictions, you
may still be eligible if your convictions are related to the same one or two incidents. For example, if you
were charged and convicted of multiple crimes during one incident, the court may choose to consider those
multiple convictions as one incident or conviction when considering your application.
WHAT TYPE OF CONVICTIONS ARE ELIGIBLE OFFENSES?
All misdemeanor convictions are eligible, and some felonies are eligible to be sealed. You can, however, seal
at most one (1) felony. Sex oenses, violent felonies and serious felonies are not eligible for sealing.
WHAT HAPPENS WHEN A RECORD IS SEALED?
The criminal record of your prior crime or crimes cannot be seen by anyone other than qualified state agencies
and state and local law enforcement, unless you are seeking to become a police or peace ocer, applying
for a gun permit, or the information is needed for law enforcement purposes.
WHAT IS THE PROCESS FOR APPLYING UNDER CRIMINAL PROCEDURE LAW §160.59?
Step 1: Visit the NY State Courts website at nycourts.gov/courthelp/sealed/ to obtain a copy of the
required forms, and instructions on how to fill them out. The instructions also contain a list of crimes
that are ineligible for sealing.
Step 2: Read and follow the instructions provided to file a motion for sealing with the court.
DO YOU HAVE A CRIMINAL CONVICTION
AND HAVE YOU REMAINED CRIME-FREE
FOR 10 YEARS?
You may be able to have up to two criminal convictions and related
charges sealed under new Criminal Procedure Law §160.59.
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Completed 2 August 2020

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