Fillable PARDON REQUEST - BACKGROUND INFORMATION FORM For Applicants (New York)

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PARDON REQUEST - BACKGROUND INFORMATION FORM For Applicants (New York)

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The Harriman State Campus, 1220 Washington Avenue, Albany, NY 12226-2050 │ (518) 457-7565 │ www.governor.ny.gov
ANDREW
M. CUOMO
Governor
PARDON REQUEST - BACKGROUND INFORMATION
FORM
For Applicants Who Committed an Eligible Non-Violent
Crime at Age 16 Or 17
Please complete this form, to the best of your knowledge, and return to:
NYS 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:
Please include information about your eligible New York State crime and conviction, if known
Arrest Charge: Arrest Agency:
Arrest Date: Your Age on Arrest Date:
Court and County of Conviction: Conviction Charge:
Sentence Received: Sentence Date:
Name and Address of Defense Attorney (if known):
Reason for Pardon Request (attach additional page or write on back with additional details if necessary):
Applicant’s Signature: Date:
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 Executive Clemency Bureau 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
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PARDON REQUEST - BACKGROUND INFORMATION FORM For Applicants (New York)

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Completed 2 August 2020

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