SUPERIOR COURT OF CALIFORNIA

COUNTY OF LOS ANGELES

CERTIFICATE OF REHABILITATION
& PARDON INSTRUCTION PACKET

FORMS INCLUDED IN THIS PACKET

General Information - Certificate of Rehabilitation
General Information – Pardon
Instruction Sheet - Certificate of Rehabilitation & Pardon
"How to Apply for a Pardon" State of CA, Office of the Governor Information Sheet from www.cdcr.ca.gov
Petition for Certificate of Rehabilitation & Pardon (Form 1)
Notice of Filing of Petition for Certificate of Rehabilitation & Pardon (Form 2)
Notice to Defendant Re: Certificate of Rehabilitation and Pardon
District Attorney Bureau of Investigations Information and Instructions Sheet
Criminal Justice Center, Department 100 Information Sheet

CRIM 121 (REV. 02/19)

 SUPERIOR COURT OF CALIFORNIA, COUNTY OF LOS ANGELES
CLARA SHORTRIDGE FOLTZ CRIMINAL JUSTICE CENTER
210 W. TEMPLE STREET
LOS ANGELES, CA 90012

GENERAL INFORMATION – PETITIONS FOR CERTIFICATE OF REHABILITATION

The granting of a Certificate of Rehabilitation restores to the applicant some of the rights of citizenship which were forfeited as a result of
a conviction. Defendants convicted of a felony, or a misdemeanor sex offense specified in Pen. Code § 290, and who were granted probation,
must obtain relief pursuant to Pen. Code § 1203.4 before a Certificate of Rehabilitation may be granted.

Purpose Does ➢ Relieve specified sex offenders of further duty to register. (Pen. Code § 290.5(a))
➢ Enhance a person’s potential for becoming licensed by state boards. (Pen. Code § 4853)
➢ Serve as an official document to demonstrate a person’s rehabilitation, which could enhance
employment possibilities.
➢ Serve as an automatic recommendation and application to the Governor for a pardon.

Does ➢ Erase the felony conviction or seal the criminal record. (Pen. Code. § 4852.17)
Not ➢ Prevent the offense from being considered as a prior conviction if the person is later
convicted of a new offense.
➢ Allow a person to answer on employment applications that one has no record of conviction.
➢ Restore the right to vote (this right is automatically restored after the person is no longer
imprisoned or on parole).
Eligibility Criteria A person is eligible to apply for a Certificate of Rehabilitation if one:

➢ Has been convicted of a felony and served a sentence in a California prison or other state penal
institution or agency;
➢ Was discharged on completion of the sentence or released on parole prior to May 13, 1943;
➢ Has not been incarcerated in a state prison or other penal institution or agency since being released;
and
➢ Presents satisfactory evidence of three years residence in California immediately prior to the filing of
the petition.
OR
➢ Was convicted of a felony or a misdemeanor sex offense specified in Pen. Code § 290, the accusatory
pleading of which was dismissed pursuant to Pen. Code § 1203.4;
➢ Has not been incarcerated in any penal institution or agency since the dismissal of the accusatory
pleading;
➢ Is not on probation for the commission of any other felony; and
➢ Presents satisfactory evidence of five years residence in California immediately prior to the filing of the
petition.
OR
➢ Was convicted of a felony and, on May 13, 1943, was confined in a state prison or other institution or
agency to which one was committed, or was convicted of a felony after May 13, 1943 and committed
to a state prison or other institution or agency.
Ineligibility Criteria Persons who are ineligible to apply for a Certificate of Rehabilitation include those who do not meet the
above eligibility criteria and those who were/are:
➢ Convicted only of misdemeanors (except those convicted of a misdemeanor sex offense specified in
Pen. Code § 290, which was dismissed pursuant to Pen. Code § 1203.4).
➢ Convicted of Pen. Code §§ 286(c), 288, 288a (c), 288.5, or 289(j).
➢ Serving mandatory life parole.
➢ Committed to prison under a death sentence.
➢ In the military service.
How to Apply A Certificate of Rehabilitation and Pardon Instruction Packet may be obtained from this court and may be
found at www.lacourt.org.

GENERAL INFORMATION – PETITIONS FOR CERTIFICATE OF REHABILITATION Pen. Code § 4852.01

 SUPERIOR COURT OF CALIFORNIA, COUNTY OF LOS ANGELES
CLARA SHORTRIDGE FOLTZ CRIMINAL JUSTICE CENTER
210 W. TEMPLE STREET
LOS ANGELES, CA 90012

GENERAL INFORMATION FOR AN APPLICATION FOR A PARDON (PEN. CODE §§ 4800 et seq. 4853)
Any person who has been convicted of a criminal offense in California may apply directly to the Governor for a pardon. The granting
of a pardon restores to the applicant some of the rights of citizenship which were forfeited as a result of the conviction. The granting of
a Certificate of Rehabilitation pursuant to Pen. Code § 4852.01 automatically serves as a recommendation and application to the
Governor for a pardon.
Purpose Does ➢ Allow an ex-felon to serve on a jury. (Code Civ. Proc. § 203.5(a)(5)).
➢ Allow restoration of firearm right, with federal approval, to specified offenders if granted a
full and unconditional pardon, unless the conviction was for a felony involving the use of a
dangerous weapon. (Pen. Code § 4854)
➢ Allow certain ex-felons to be considered for appointment as a county probation officer or
state parole agent, but not to any other peace officer positions. (Gov. Code § 1029)
➢ Allow specified sex offenders still required to register after obtaining a Certificate of
Rehabilitation to be relieved of the duty to register. (Gov. Code § 290.5(b)(1))
Does ➢ Seal or erase the record of conviction. (Pen. Code. § 4852.17)
Not ➢ Prevent the pardoned offense from being considered as a prior conviction if the person is
later convicted of a new offense.
➢ Allow a pardoned person to answer on employment applications that one has no record of
conviction.
➢ Restore ability to own a firearm to ex-felons convicted of any offense involving the use of a
dangerous weapon. (Pen. Code § 4854)
➢ Pardon convictions from another state or federal convictions.
➢ Necessarily prevent deportation.

Traditional Pardon The traditional pardon procedure, see Pen. Code §§ 4800-4813, is available to those persons who are
ineligible to petition for a Certificate of Rehabilitation. This procedure is used primarily, although not
exclusively, by California ex-felons who reside out-of-state and are therefore unable to satisfy the residency
requirement. The traditional pardon procedure is also available to those individuals who have convictions
for Pen. Code §§ 286(c), 288, 288a(c), 288.5 and 289(j).

How to Apply A Certificate of Rehabilitation and Pardon Instruction Packet may be obtained from this court and may be
found at www.lacourt.org.

GENERAL INFORMATION – PARDON Pen. Code §§ 4800, 4853

 SUPERIOR COURT OF CALIFORNIA, COUNTY OF LOS ANGELES
CLARA SHORTRIDGE FOLTZ CRIMINAL JUSTICE CENTER
210 W. TEMPLE STREET
LOS ANGELES, CA 90012

INSTRUCTION SHEET – CERTIFICATE OF REHABILITATION & PARDON

Certificate of Eligibility Refer to the “How to Apply for a Pardon” information forms from the Office of the Governor of the
Rehabilitation State of California to determine eligibility.
District Attorney The Office of the District Attorney reviews and confirms eligibility requirements
and may conduct an investigation regarding rehabilitation.
Filing Fees There is no filing fee or any other court-related fee required when filing a Certificate of Rehabilitation.
(Pen. Code § 4852.09)

Filing the 1. The petitioner must complete the following forms:

Petition ➢ Notice of Filing for Certificate of Rehabilitation and Pardon (Form 2) – leaving the date, time,
and department area blank.
➢ Petition for Certificate of Rehabilitation and Pardon. (Form 1)

2. The forms must be submitted or mailed to one of the following locations:

Office of the District Attorney CLARA SHORTRIDGE FOLTZ

ATTN: Bureau of Investigations OR CRIMINAL JUSTICE CENTER
211 W. Temple Street, Suite 300 210 W. Temple. Street, Department 100
Los Angeles, CA 90012 Los Angeles, CA 90012

Order to If the District Attorney’s Office determines the petitioner has not met the required eligibility criteria, it
Show Cause will notify the petition and court of the ineligibility status. Upon receiving such notice, the court will
Hearing take no further action in the matter unless the petitioner files a motion to issue an Order to Show
Cause regarding eligibility.

Hearing If the District Attorney’s Office determines that the petitioner has met the eligibility criteria, all parties
Date will be mailed notice of the hearing date.

Providing Once a rehabilitation hearing date is set, the District Attorney’s Office will send copies of the Notice
Notice to the of Filing for Certificate of Rehabilitation and Pardon (Form 2) and the Petition for Certificate of
D.A. and Rehabilitation and Pardon (Form 1) to:
Governor ➢ The Governor of California.
➢ The District Attorney of each county in which the petitioner was convicted of a felony.

The District Attorney’s Office will send notification to each of these offices as least thirty (30) days
before the hearing.

Pardon Upon the granting of a Certificate of Rehabilitation, the court will forward the order to the Governor. This order
constitutes an application for a pardon.

INSTRUCTION SHEET – CERTIFICATE OF REHABILITATION & PARDON

 State of California
Office of Governor Edmund G. Brown Jr.

How to Apply for a Pardon

Individuals who have been convicted of a crime in California may apply to the Governor for a
pardon. A gubernatorial pardon is an honor that may be granted to people who have demonstrated
exemplary behavior following their conviction. A pardon will not be granted unless it has been earned.
Obtaining a pardon is a distinct achievement based upon proof of a productive and law-abiding life
following conviction. Historically, governors have granted very few pardons.

Applications generally will not be considered unless the applicant has been discharged from
probation or parole for at least 10 years without further criminal activity during that period. There is no
fee for applying for a pardon.

The Governor of California cannot grant a pardon for a conviction from another jurisdiction,
such as another state or a federal proceeding. A person convicted in another state must apply for a
pardon in that state. Federal pardon information may be obtained from the Pardon Attorney, U.S.
Department of Justice, 500 First Street Northwest, Washington, D.C. 20530.

The Application Process

For most people, the first step in applying for a pardon is to obtain a Certificate of Rehabilitation
from the Superior Court in the county where the applicant currently lives. People who live outside of
California and people who are ineligible for a Certificate of Rehabilitation must use a direct pardon
application. The procedure utilized will depend on the circumstances of each applicant.

1. Certificate of Rehabilitation

A Certificate of Rehabilitation is a court order declaring that a person convicted of a crime is

now rehabilitated. Generally, any person convicted of a felony who still resides in California may apply
to the Superior Court in the county where he or she lives for a Certificate of Rehabilitation, provided
that the applicant meets the legal requirements of demonstrated rehabilitation. There are special rules
that apply to individuals convicted of sex offenses.

An application for a Certificate of Rehabilitation can usually be obtained from the court clerk,
probation department, or public defender's office. Once a petition is filed, the court may require an
investigation by the district attorney and will schedule a hearing.

If the Court issues a Certificate of Rehabilitation, the certificate is forwarded to the Governor’s
Office where it automatically becomes an application for a pardon. The Governor’s receipt of a
Certificate of Rehabilitation does not guarantee that a pardon will be granted.

2. Direct Pardon

The direct pardon procedure is available to people who are ineligible for a Certificate of
Rehabilitation. This procedure is used primarily by people who were convicted of a crime in California
and now reside outside the state. The direct pardon procedure is also available to people who are not
eligible for a Certificate of Rehabilitation because they have been convicted of specified sex offenses or
misdemeanor offenses.

Revised 10/24/2018 1
 Applicants for a direct pardon may obtain the application either by accessing the Governor’s
website at https://www.gov.ca.gov/pardons-and-commutations/, or by requesting an application in
writing at the following address:

Governor's Office
State Capitol
Attention: Legal Affairs
Sacramento, CA 95814

The applicant should first complete the Application for Executive Clemency. Then the applicant must
send the Notice of Intent to Apply for Executive Clemency to the District Attorney of each county in
which the applicant was convicted so that each District Attorney receives the legally-required notice.
The District Attorney acknowledges receipt of the Notice of Intent and returns the notice to the
Governor’s Office. Finally, the applicant should return the completed application to the Governor’s
Office at the address listed above.

The Review Process

There is no requirement that the Governor take any action on an application for a pardon. Once
a Certificate of Rehabilitation or a completed direct pardon application is received by the Governor’s
Office, the Office typically forwards the application to the Board of Parole Hearings (Board). The Board
may conduct a background investigation and make a recommendation on whether a pardon should be
granted. The Board may contact the District Attorney, investigating law enforcement agency, and other
persons with relevant information on the applicant.

If the applicant has been convicted of more than one felony, the California Supreme Court must
recommend granting a pardon before the Governor may do so. However, there is no obligation that the
Governor seek a recommendation from the Supreme Court, in the first instance.

The length of time needed to complete the pardon process cannot be predicted. Once a
completed application has been received by the Governor’s Office, it is not necessary to contact the
Governor’s Office to check on the status of an application. If the Governor takes action on an
application, the applicant will be notified. Applicants should notify the Governor’s Office in writing if
their mailing address changes.

Effect of a Pardon

A pardon does not seal the individual's criminal record or expunge the record of conviction,
and the pardon is itself a public record. When a pardon is granted, the California Department of Justice
and the Federal Bureau of Investigation are notified so that they may update their records on the
applicant. The pardon is filed with the Secretary of State, reported to the Legislature, and is a public
record. If a pardon is granted, the Certificate of Rehabilitation or the application for a direct pardon will
be reported to the Legislature in an annual report and will become a public record. However, specific
personal information will be redacted (hidden) before the Certificate of Rehabilitation or the application
is made available to the public.

Please see the attached “Quick Reference for Restoration of Rights” for a detailed description of
the effects of obtaining a Certificate of Rehabilitation and a pardon.

Revised 10/24/2018 2
 CERTIFICATE OF REHABILITATION AND PARDON
QUICK REFERENCE FOR RESTORATION OF RIGHTS

In California, the granting of a Certificate of Rehabilitation or a Governor’s pardon restores to the

applicant some rights of citizenship that were forfeited as a result of a conviction.

CERTIFICATE OF REHABILITATION GOVERNOR’S PARDON

DOES: DOES:

 Relieve some sex offenders, as specified,  Allow a felon to serve on a jury trial.
of further duty to register. (Code Civ. Proc., § 203 subd. (a)(5).)
(Pen. Code, § 290.5.)  Allow restoration of firearms rights, upon
 Enhance a felon’s potential for licensing federal approval, to specified offenders
consideration by a State board. who have obtained a certificate of
(Pen. Code, § 4853.) rehabilitation if granted a full and
 Serve as an official document to unconditional pardon, unless the
demonstrate a felon’s rehabilitation, conviction was for a felony involving the
which could enhance employment use of a dangerous weapon. (Pen. Code,
possibilities. §4852.17.)
 Serve as an automatic application for a  Allow a felon to be considered for
gubernatorial pardon. appointment as a county probation officer
or a state parole agent, but not to any other
peace officer positions.
(Gov. Code, § 1029, subd. (c).)
 Allow specified sex offenders still required
to register after obtaining a Certificate of
Rehabilitation to be relieved of their duty
to register if granted a full and
unconditional pardon.
DOES NOT: (Pen. Code, § 290.5.)

 Erase the felony conviction or seal the DOES NOT:

criminal record.
(Pen. Code, § 4852.17.)  Seal or erase the record of conviction.
 Prevent the offense from being (Pen. Code, § 4852.17.)
considered as a prior conviction if the  Prevent the pardoned offense from being
person is later convicted of a new considered as a prior conviction if the
offense. person is later convicted of a new offense.
 Allow a felon to answer on employment  Allow a pardoned person to answer on
applications that he/she has no record of employment applications that he/she has
conviction. no record of conviction.
 Give a felon the right to vote, because  Restore ability to own a firearm to felons
this right is automatically restored after convicted of any offense involving the use
discharge from parole. of a dangerous weapon.
 Restore the right to own or possess (Pen. Code, § 4854.)
firearms.  Pardon convictions from another state, or
federal convictions.
 Necessarily prevent deportation.
Revised 10/24/2018 3
 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 all that apply ]

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

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
Felony conviction was reduced to a misdemeanor (Provide court information):__________________;
FORM 1 (Revised 1/02/2019) This form was prepared by the Board of Parole Hearings 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 all that apply ]
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

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

Felony conviction was reduced to a misdemeanor (Provide court information):__________________;

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 all that apply ]

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

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

Felony conviction was reduced to a misdemeanor (Provide court information):__________________;

FORM 1 (Revised 1/02/2019) This form was prepared by the Board of Parole Hearings 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.(Pen. Code, § 4852.05.)

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

Applicant’s Drivers License Number

Applicant’s Email Address

Applicant’s Home Phone Number

Applicant’s Work Phone Number

Applicant’s Cell Phone Number

FORM 1 (Revised 1/02/2019) This form was prepared by the Board of Parole Hearings pursuant to Penal Code Section 4852.18.
 FORM 1 INSTRUCTIONS
1. Obtain Your Criminal Records

To complete this form, you will need information regarding each of your felony convictions, including the
date of each conviction, the specific charge or charges for which you were convicted, the county of the
conviction, and the sentence that was given. In addition, you will need to know the date that you were
released from prison or jail and/or discharged from parole or probation.

This information may be obtained through the court in which the conviction(s) took place, or you may obtain
a copy of your state criminal record through the California Department of Justice. You may only obtain your
own records from the Department of Justice. Information regarding this request may be obtained through
the Office of the Attorney General website at https://oag.ca.gov/fingerprints/record-review. Regardless of
the number of convictions, you will be filing only a single petition.

2. Confirm Your Eligibility

You are ineligible for a certificate of rehabilitation if any of the following are true:

• You were convicted only of misdemeanors (other than sex offenses defined in Penal
Code section 290, which were subsequently expunged) (Pen. Code, §4852.01, (b).)

• You were convicted of specific sex crimes involving minor children as enumerated
under Penal Code sections 286, subdivision (c), 288, 288a, subdivision (c), 288.5, and
289, subdivision (j). (Pen. Code, § 4852.01, (c).)

• You are serving mandatory life parole. (Pen. Code, § 4852.01, (c).)

• You were sent to state prison under a death sentence. (Pen. Code, § 4852.01, (c).)

• You are currently in military service. (Pen. Code, § 4852.01, (c).)

Minimum Period of Rehabilitation

In order to be granted a certificate of rehabilitation you must satisfy a minimum period of rehabilitation. In
every case, you must have resided continuously for five years in this state prior to filing the petition. (Pen.
Code, § 4852.06) The period of rehabilitation begins to run upon your discharge from custody or upon
release on parole or probation, whichever is sooner. (Pen. Code, § 4852.03, (a).) The period of
rehabilitation shall constitute five years residence in this state, plus a period of time determined by the
following rules:

• An additional four years in the case of any person convicted of violating Section 187
(murder), 209 (aggravated kidnapping), 219 (derailing or wrecking a train), 4500 (assault
with force likely to cause great bodily injury), or 12310 (use of explosives or destructive
devices causing death, mayhem, or great bodily injury) of the Penal Code, or subdivision
(a) of Section 1672 of the Military and Veterans Code (acting or failing to act so as to
cause another person’s death), or any other offense which carries a life sentence. (Pen.
Code, § 4852.03, (a)(1).)

• An additional five years in the case of any person convicted of any offense or attempted
offense for which sex offender registration is required pursuant to Penal Code 290,
except for convictions for violations of subdivision (b), (c), or (d) of Section 311.2
(possession or distribution of media depicting a minor engaging in sexual conduct), or of
Section 311.3 (sexual exploitation of a child), 311.10 (advertising obscene matter
depicting a minor engaging in sexual conduct), or 314 (indecent exposure). For those
convictions, two years shall be added to the five years imposed by this section. (Pen.
Code, § 4852.03, (a)(2).)
 • An additional two years in the case of any person convicted of committing any offense
not listed above and which does not carry a life sentence. (Pen. Code, §4852.03, (a)(3).)

• Additionally, the trial court hearing your application for a certificate of rehabilitation may
add additional years if you served consecutive sentences. The amount of additional time
will not exceed the sum of the maximum penalties for all your crimes. (Pen. Code, §
4852.03, (a)(4).)

Felony Probation

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.

3. File Your Documents

• After completing the Petition for Certificate of Rehabilitation and Pardon, you must file it
with the superior court in the county in which you reside. (Pen. Code, § 4852.06.)

• You are entitled to be represented by an attorney of your own selection, or by the public
defender. (Pen. Code, § 4852.08.)

• 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 Division of
Juvenile Facilities. (Pen. Code, § 4852.04)

• 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. (Pen. Code, § 4852.2.)

• You are not required to pay filing fees of any kind in connection with this proceeding. (Pen.
Code, § 4852.09.)

4. Notice of Filing

When the court sets a hearing date on your petition, you are required to give notice of that date at least 30
days before the hearing. You must formally notify the District Attorney for each county in which you have
been convicted, the county in which the petition is filed, and the Governor's Office. (Pen. Code, § 4852.07.)
For more information on the notice requirements, please reference the Notice of Filing of Petition for
Certificate of Rehabilitation and Pardon.

5. After a Certificate of Rehabilitation is Issued

A certificate of rehabilitation is not an automatic pardon; it is only an automatic application for a pardon. In
the event that a certificate of rehabilitation is issued by a court, the certificate of rehabilitation shall be
reviewed by the Board of Parole Hearings within one year. Thereafter, the Board shall issue a
recommendation as to whether the Governor should pardon that individual. (Pen. Code, § 4852.16, (b).)
 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)

NOTICE OF FILING OF PETITION FOR CERTIFICATE OF REHABILITATION AND PARDON

Pursuant to Penal Code Sections 4852.01 and 4852.06

To the Governor of the State of California:

District Attorney, County of ;

County of Residence

District Attorney, County of ;

Most recent felony in county of conviction, if different from County of Residence

District Attorney, County of ;

2nd most recent felony in county of conviction, if applicable

District Attorney, County of ;

3rd most recent felony in county of conviction, if applicable

You and Each of You Will Please Take Notice That On the day of ;
Date you filed your Petition for Certificate of Rehabilitation and Pardon

the undersigned has filed a petition in the above-mentioned court(s) for a Certificate of Rehabilitation and

Pardon in accordance with the provision of Chapter 3.5, Title 6, Part 3 of the Penal Code of the State of

California, and that said petition has, by said court, been set for a hearing on the day of
Day of hearing

to commence at a.m. p.m., of said day, or as soon

Month, Year Time of hearing

as the matter can be heard, in its courtroom, department at the courthouse

Department

in the city of ,county of state of California.

City where hearing will be held County where hearing will be held

Applicant's Signature Month Day, Year

Applicant's Street Address

Applicant's City, State ZIP Code

FORM 2 (Revised 1/02/2019) This form was prepared by the Board of Parole Hearings pursuant to Penal Code Section 4852.18.
 AFFIDAVIT OF SERVICE BY MAIL

STATE OF CALIFORNIA
City of , County of

I, being first duly sworn, deposes, and says:

Full Name - First Middle Last and Suffix, if applicable

I am a citizen of the United States, am over the age of 18 years, and am not a party to the above-entitled

proceeding. I am a resident of the County of , State of California.

County of Residence

My residence business address is

Street Address

City, State ZIP Code

On the day of , I served the attached Notice to each person listed below
Day of the Month Month, Year

Full Name - First Middle Last and Suffix, if applicable Street Address County

Full Name - First Middle Last and Suffix, if applicable Street Address County

Full Name - First Middle Last and Suffix, if applicable Street Address County

Full Name - First Middle Last and Suffix, if applicable Street Address County

by placing a copy of this Notice in a sealed envelope and mailing it first class, postage pre-paid to each

person listed above. There is a delivery service by United States mail at each of the places so

addressed, or there is a regular communication by mail between the place of mailing and each of the

places so addressed.

Subscribed and sworn to before me this day of .

Day of the Month Month, Year

Full Name of Notary Public - TYPED or PRINTED Notary Public - SIGNATURE

In and for the City of , County of , California.

FORM 2 (Revised 1/02/2019) This form was prepared by the Board of Parole Hearings pursuant to Penal Code Section 4852.18.
 NOTICE OF SERVICE IN PERSON
Receipt of copy of this Notice is hereby admitted this day of .
Day of the month Month, Year

Governor's Office
State Capitol
Legal Affairs Division

Full Name of Governor's staff - TYPED or PRINTED Governor's staff - SIGNATURE

Governor's staff - TITLE Month Day, Year

Receipt of copy of this Notice is hereby admitted this day of .

Day of the month Month, Year

Full Name of District Attorney staff - TYPED or PRINTED District Attorney staff - SIGNATURE

County District Attorney Month Day, Year

Receipt of copy of this Notice is hereby admitted this day of .

Day of the month Month, Year

Full Name of District Attorney staff - TYPED or PRINTED District Attorney staff - SIGNATURE

County District Attorney Month Day, Year

Receipt of copy of this Notice is hereby admitted this day of .

Day of the month Month, Year

Full Name of District Attorney staff - TYPED or PRINTED District Attorney staff - SIGNATURE

County District Attorney Month Day, Year

Receipt of copy of this Notice is hereby admitted this day of .

Day of the month Month, Year

Full Name of District Attorney staff - TYPED or PRINTED District Attorney staff - SIGNATURE

County District Attorney Month Day, Year

FORM 2 (Revised 1/02/2019) This form was prepared by the Board of Parole Hearings pursuant to Penal Code Section 4852.18.
 FORM 2 INSTRUCTIONS

1. After completing this Notice of Filing for Certificate of Rehabilitation and Pardon, Penal Code
section 4852.07 requires that you distribute one (1) copy to:

 the Governor of California;

 the District Attorney in your county of residence where you filed your Petition for Certificate of
Rehabilitation and Pardon, and;
 the District Attorney of each county in which you were convicted of a felony.
2. This Notice of Filing for Certificate of Rehabilitation and Pardon must be served to all of these
individuals at least thirty days prior to the date set for your hearing. (Pen. Code, § 4852.07.) You
may do so by using one or both of the following forms:

• Affidavit of Service by Mail (Form 2A) - If you intend to have a Notary Public mail a copy of the
Notice of Filing for Certificate of Rehabilitation and Pardon, you may do so by having the
Notary Public complete and sign the Affidavit of Service by Mail. Mailing procedures are
outlined in the Affidavit.

• Notice of Service in Person (Form 2B) - If you intend to hand-deliver a copy, you may do so by
using this form and having each individual sign in the appropriate space indicating that a copy of
the Notice of Filing for Certificate of Rehabilitation and Pardon was received.

3. After you have served each individual, personally or by mail, file this completed Notice of Filing for
Certificate of Rehabilitation and Pardon and the Affidavit of Service by Mail or Notice of Service
in Person, or both, with the Superior Court in the county in which you reside.
 NOTICE TO DEFENDANT
RE: CERTIFICATE OF REHABILITATION AND PARDON

Any person convicted of a felony the During the proceedings upon the petition,
accusatory pleading of which has been the petitioner may be represented by
dismissed pursuant to Penal Code Section counsel of his own selection; if he has no
1203.4 may file a petition for Certificate of such counsel he shall be represented by the
Rehabilitation and Pardon provided the public defender.
petitioner has not been incarcerated in any
prison, jail, detention facility or other penal No filing fee nor court fees of any kind are
institution or agency since the dismissal of required.
the accusatory pleading and is not on
probation for the commission of any other Forms for petitioning for a Certificate of
felony, and petitioner presents satisfactory Rehabilitation and Pardon are available from
evidence of three years residence in this the Clerk’s Office or via the Los Angeles
state prior to the filing of the petition. Superior Court’s website at www.lacourt.org.

After the expiration of the minimum period Information regarding eligibility and
of rehabilitation applicable after the additional assistance may be obtained from:
termination of probation, a person may file
in the superior court of the county in which Office of the Public Defender
he then resides a petition for ascertainment Clara Shortridge Foltz Criminal Justice
and declaration of the fact of his Center
rehabilitation and of matters incident 210 W. Temple Street
thereto, and for a Certificate of Los Angeles, CA 90012
Rehabilitation. Tel. (213) 974-2811

The petitioner shall give notice of the filing

of the petition to the district attorney of the
county which the petition is filed, to the
district attorney of each county in which the
petitioner was convicted of a felony or of a
crime the accusatory pleading of which was
dismissed pursuant to Penal Code Section
1203.4, and to the office of the Governor,
together with notice of the time of the
hearing of the petition, at least 30 days prior
to the date set for such hearing.
 DISTRICT ATTORNEY
BUREAU OF INVESTIGATIONS

INFORMATION AND INSTRUCTIONS FOR PETITIONER

FOR CERTIFICATE OF REHABILITATION AND PARDON

Section 4852.12 of the California Penal Code states, “…the court…may request from the District
Attorney an investigation of the residence of the petitioner, the criminal record of the petitioner
as shown by the records of the Department of Justice, any representation made to the court by
the applicant,…and any other information the court may deem necessary in making its
determination…”

As outlined above, the District Attorney will conduct an investigation and submit a report to the
judge in Department 100 of the Los Angeles Superior Court. Copies of this report are distributed
to the Public Defender, County Clerk, and the Governor’s Legal Affairs Secretary. The Public
Defender’s Office will notify you when you are scheduled for appearance in Department 100 and
the Deputy Public Defender will represent you before the judge. If the judge feels you have
demonstrated by your record that you are a responsible citizen, he will grant you a Certificate of
Rehabilitation which will be forwarded to the Governor’s Legal Affairs Secretary for consideration
by the Pardon Board. The investigation for the pardon will be conducted by the Community
Release Board, who will send you another, more detailed questionnaire.

It is not the desire of this office to expose your past behavior. If, during the course of our
investigation, anyone asks why we are inquiring about you, we answer that we are conducting a
confidential investigation at your request. We do not talk to neighbors but may verify your
employment with your immediate supervisor. Your references will receive a form letter.

If you wish to inquire about your voting status, you should contact the Registration Division,
Registrar of Voters, 12400 Imperial Highway, Norwalk, California, 90650, telephone number (800)
815-2666.

A pardon will not:

1. Allow you to carry a firearm if you were convicted of a felony involving the use of a
dangerous weapon (Penal Code § 4852.17);
2. Allow you to fill out job applications omitting your felony record;
3. Assure absolutely a better job. This depends on your employer; and
4. Expunge your record. Your criminal record will still be available to law enforcement
agencies.
 DISTRICT ATTORNEY
BUREAU OF INVESTIGATIONS
REHABILITATION AND PARDON INFORMATION SHEET
FROM THE PUBLIC DEFENDER’S OFFICE

In order that the investigation requested by the petition seeking a Rehabilitation and Pardon be
completed in a timely fashion your assistance in providing the following information is requested.

1. Case number or numbers petitioner is seeking rehabilitation for:

________________________________________________________________________
________________________________________________________________________
________________________________________________________________________

2. What was the petitioner charged with?

________________________________________________________________________
________________________________________________________________________
________________________________________________________________________

3. Conviction date for each case applying for:

________________________________________________________________________
________________________________________________________________________
________________________________________________________________________

4. Date petitioner placed on parole or probation for each case:

________________________________________________________________________
________________________________________________________________________
________________________________________________________________________

5. C.I.I. number for petitioner: _________________________________________________

6. What is petitioner’s 1203.4 P.C. date? _________________________________________

 PLEASE NOTIFY THIS OFFICE BY MAIL OF ANY ADDRESS CHANGES:

LOS ANGELES COUNTY DISTRICT ATTORNEY

ATTN: BUREAU OF INVESTIGATIONS
211 W. TEMPLE STREET, STE. 300
LOS ANGELES, CA 90012

NOTE: The attached Rehabilitation and Pardon form must be completely filled out
in detail when submitted or the questionnaire will be returned to you for
completion. This will delay your court date.

I acknowledge receipt of this rehabilitation and pardon information package.

x________________________________
Petitioner’s Signature
 Department 100

Legal Name
Last First Middle

What other names have you used

If married, maiden name

Residence Address
Number Street

City County Zip Code

How long have you lived at this address

Nearest large intersection

Res. phone Bus. phone

U.S. Citizen Yes ____ No ____
Are you a legal resident of the United States: Yes ____ No ____
If alien resident of the United States, what is your Alien Registration Number
_________________________

Birthplace Birth date Sex

City State

Height _______ Weight ______ Hair _____ Eyes ______ Decent _____ Race ______

Driver’s License Number ___________________________________________________

Social Security Number ____________________________________________________

Present Marital Status □ Single □ Married □ Divorced □ Widow(er)

Date Marriage Performed
Month / Date/ Year City State

Living with Spouse: Yes _____ No _____

Spouse’s Name _____________________________________ Birthdate _____________

Month / Date/ Year

Height _______ Weight _______ Hair ______ Eyes ______ Decent ______ Race ______

Circle Last Grade Completed

Grammar School 5 6 7 8 High School 9 10 11 12 College 1 2 3 4 5 6
Employment: List employments since your release.

(Last or Present)
________________________________________________________________________
Date (From – To) Name of Employer Phone

________________________________________________________________________
Number Street City State Zip Code

________________________________________________________________________
Department Job Title Annual Salary Immediate Supervisor

________________________________________________________________________
Reason for Leaving

(Previous)
________________________________________________________________________
Date (From – To) Name of Employer Phone

________________________________________________________________________
Number Street City State Zip Code

________________________________________________________________________
Department Job Title Annual Salary Immediate Supervisor

________________________________________________________________________
Reason for Leaving

(Previous)
________________________________________________________________________
Date (From – To) Name of Employer Phone

________________________________________________________________________
Number Street City State Zip Code

________________________________________________________________________
Department Job Title Annual Salary Immediate Supervisor

________________________________________________________________________
Reason for Leaving