CERTIFICATE OF REHABILIATION Optional Use Form: L-410.2 [Rev.

July 15, 2011] Penal Code § 4852.13 SUPERIOR COURT OF CALIFORNIA, COUNTY OF ORANGE CENTRAL JUSTICE CENTER CIVIC CENTER DRIVE WEST POST OFFICE BOX SANTA ANA, CA 92702-2024 For Court Use Only In the Matter of the Application of _________________________________________________________ Petitioner’s full name – First Middle Last and Suffix, if applicable Date of Birth: CII Number: Criminal Case Number(s): ____________________________________________ CERTIFICATE OF REHABILITATION (Penal Code § 4852.13) CERTIFICATE NUMBER: M - The petition of , presently residing Type Applicant’s Full Name - First Middle Last and Suffix, if applicable at , requesting a Type Applicant's Street Address, City, State, and ZIP Code a Certificate of Rehabilitation pursuant to the provisions of

Chapter 3.5, Title of Part of the Penal Code of the State of California, was heard on Date and proof having been made to the satisfaction of the Court that notice of the time of hearing has been regularly given as required by law; and from satisfactory proof taken at said hearing the Court finds that all allegations of said petition are true, and that the required period of rehabilitation has elapsed since petitioner's date of discharge from custody due to completion of the term to which the petitioner was sentenced, or upon the release on parole or probation on , that, where appropriate, petitioner has obtained relief pursuant to Penal Month Day, Year Penal Code

section 1203.4, and that petitioner has demonstrated by the course of conduct his/her rehabilitation and fitness to exercise all the civil and political rights of citizenship (except as provided in Penal Code

section 4852.15); and that the that petitioner has been time(

s) convicted of a felony; Total Number of Felony Convictions The Certificate of Rehabilitation is granted. This Court declares the petitioner has been rehabilitated and is fit to exercise all the civil and political rights of citizenship (except as provided in Penal Code

section 4852.15), and this Court recommends that the Governor of the State of California grant a full pardon to said petitioner. Dated: Judicial Officer - TYPED or PRINTED Judicial Officer - SIGNATURE This form was prepared under the direction of the Office of the Attorney General of the State of California