GovernorEdmundG.BrownJr.

SttateCapitolSSacramento,Caalifornia95814
4

APPLICATIONFOREXECUTIV ECLEMENCY

Completethisapplicattiontorequesstapardonorcommutation
nfromtheGoovernor.Aparrdonisthefo rgivenessofaacrimeanda
minationofassentence.IfyouareeligibleeforaCertificcateofRehab ilitation,don
notcomplete
commuttationisareductionorelim
thisapp lication;inste
eadobtainaCertificateofR
Rehabilitationfromthesup eriorcourtin yourcountyo
ofresidence. (SeePenal
apardonisgranted,thisap
pplicationwillbecomeapu
ublicrecord,h
howeverspeccificpersonal information
Code, 4852.01.)Ifa
den)beforeittismadeavaiilabletothep
public.
willberredacted(hidd

APPLICAN
NTINFORMATI ON

Name:____________
____________
_____________
__DateofBirth:_________
_____SocialSSecurityNumb
ber:_____________________
__

Address::___________
_____________
____________
_____________
______________________________________________________________
__

1.

ConvictionSummary:

Listallpriorrconvictions,,includingan
nyinothersttatesorcoun
ntries.Attach
hadditionalp
pagesifneceessary.
Offense(s):
Dateofoffense(s):
Counttyofconviction
n(s):
Sentence(s):

Brieflydescrib
bethecircumsstancesofthecrime(s)forw
whichyouarerrequestingapaardonorcomm
mutation(attaachadditional
2.
pagesasnece
essary):

____________
_____________
____________
_______________________________________________________________
__
____________________
____________________
____________
_____________
____________
_______________________________________________________________
__
____________________
____________
_____________
____________
_______________________________________________________________
__
____________________
____________
_____________
____________
_______________________________________________________________
__

3.

Explainwhyyyouarerequesstingapardonorcommutatiion(attachadd
ditionalpagessasnecessary)):

____________________
____________
_____________
____________
_______________________________________________________________
__
____________________
____________
_____________
____________
_______________________________________________________________
__
____________________
____________
_____________
____________
_______________________________________________________________
__
____________________
____________
_____________
____________
_______________________________________________________________
__

4.
Provideabrie
efstatementexplainingwhyyyoushouldbe
egrantedapaardonorcomm
mutation(attacchadditionalp
pagesif
necessary):

____________
_____________
____________
_______________________________________________________________
__
____________________
____________________
____________
_____________
____________
_______________________________________________________________
__
____________________
____________
_____________
____________
_______________________________________________________________
__

5.
Ifyouhavepa
aidanymoneyyorgivenanyggifttoanyonetoassistinth
hepreparationofthisapplicaation,listtheirrname,
address,anda
amountpaido
orgiven(requiiredbyPenalC
Codesection44807.2):

____________
_____________
____________
_______________________________________________________________
__
____________________
Rev.08/01//13
ApplicationforExecutiveClemency,Page
e1

STATEMENTOFNOTICETODISTRICTATTORNEYANDDECLARATIONUNDERPENALTYOFPERJURY

ThisapplicationmaybesubmittedtotheBoardofParoleHearingsforinvestigationandrecommendationpursuanttoPenal
Codesection4812.Thisapplicationmayalsobesubmittedtolawenforcementorotheragenciesforinvestigationorrecommendation.
PenalCodesections4804and4805requirethatyougivetheDistrictAttorneyinthecountyofconvictionwrittennoticeofyour
intentiontoapplyforapardonorcommutation.YoumustcompletetheNoticeofIntenttoApplyforExecutiveClemency(attached)and
mailittotheDistrictAttorneybeforesubmittingthisapplicationtotheGovernorsOffice.Ifyouarerequestingapardonformorethan
oneconvictioninvolvingmorethanonecounty,eachDistrictAttorneymustbegivennotice.

I,_________________________________,declareunderpenaltyofperjuryunderthelawsoftheStateofCaliforniathatI
(PrintFullName)
haveservedtheDistrictAttorneyoftheCountyof____________________________withnoticeofmyintenttoapplyforapardonor

(NameofCounty*)
commutation.

IfurtherdeclareunderpenaltyofperjuryunderthelawsoftheStateofCaliforniathattheinformationIhaveprovidedonthis
applicationistrueandcorrect.Iunderstandthatanyomissionormisstatementoffactsmayresultinthedenialoftheapplicationand
thefilingofperjurychargesagainstme.

ApplicantsSignature

Date

*IfApplicable,ListAdditionalCountiesHere(SendNoticeofIntenttoApplyforExecutiveClemencytoAllCountiesListed)

Rev.08/01/13
ApplicationforExecutiveClemency,Page2

NOTICEOFINTENTTOAPPLYFOREXECUTIVECLEMENCY
ThisnoticeisrequiredbyPenalCodesections4804and4805.

TotheDistrictAttorneyof__________________County:PleasetakenoticethatI,_________________________________,

wasconvictedofthecrimeof___________________________________________________________________________________,

committedin______________________________________County,California,onthedateof____________________________.

IwillsubmitthisapplicationtotheGovernoroftheStateofCaliforniaforthefollowingtypeofexecutiveclemency(checkone):

Pardon

Commutationofsentence.InmateNumber:_________________.

ApplicantsSignature

Date

DISTRICTATTORNEYACKNOWLEDGEMENT
ThissectiontobecompletedbytheDistrictAttorneyonly.

I,____________________________________________,DistrictAttorneyoftheCountyof__________________________,

doherebyacknowledgereceiptofnoticefrom_____________________________________________________________________,

thathe/sheintendstoapplytotheGovernoroftheStateofCaliforniaforapardonoracommutationofsentence.

Signed____________________________________________

Date____________________________________________

DistrictAttorney:PleaseReturnthisNoticetotheGovernorsOffice,Attn:LegalAffairs,StateCapitol,Sacramento,CA95814.

Rev.08/01/13
NoticeofIntentiontoApplyforExecutiveClemency