Application For Certificate Of Pardon For Simple Possess

OMB Control No: 1123-0014

APPLICATION FOR CERTIFICATE OF PARDON FOR SIMPLE POSSESSION OF MARIJUANA

Instructions:

If you were charged with or convicted of simple possession of marijuana by either a federal or

D.C. Superior court and qualify for the pardon issued by President Biden’s proclamation of October 6, 2022, you may obtain an individual Certificate of Pardon showing that the proclamation applies to you. If you believe that the proclamation applies to you and wish to obtain such a certificate, complete and return this application with the required documents to USPardon.Attorney@usdoj.gov or U.S. Department of Justice, Office of the Pardon Attorney, 950 Pennsylvania Avenue, Washington, DC 20530.

Provide the following: (1) the charging document (the indictment, complaint, or criminal information); and/or (2) the judgment of conviction or the court docket sheet showing the sentence and date it was imposed. If documentation cannot be obtained to verify your charges or conviction, the Office of the Pardon Attorney may be unable to issue you a Certificate of Pardon. Note: Submit a separate form for each conviction or charge for which you are seeking a certificate of pardon.

Privacy Act Statement:

The Office of the Pardon Attorney has authority to collect this information under the U.S. Constitution, Article II, Section 2 (the pardon clause); Orders of the Attorney General Nos. 1798-93, 58 Fed. Reg. 53658 and 53659 (1993), 2317-2000, 65 Fed. Reg. 48381 (2000), and 2323-2000, 65 Fed. Reg. 58223 and 58224 (2000), codified in

28 C.F.R. §§ 1.1 et seq. (the rules governing petitions for executive clemency); and Order of the Attorney General No. 1012-83, 48 Fed. Reg. 22290 (1983), as codified in 28 C.F.R. §§ 0.35 and 0.36 (the authority of the Office of the Pardon Attorney). The principal purpose for collecting this information is to enable the Office of the Pardon Attorney to issue an individual certificate of pardon to you. The routine uses which may be made of this information include provision of data to the President and his staff, other governmental entities, and the public.

The full list of routine uses for this correspondence can be found in the System of Records Notice titled, “Privacy Act of 1974; System of Records,” published in Federal Register, September 15, 2011, Vol. 76, No. 179, at pages 57078 through 57080; as amended by “Privacy Act of 1974; System of Records,” published in the Federal Register, May 25, 2017, Vol. 82, No. 100, at page 24161, and at the U.S. Department of Justice, Office of Privacy and Civil Liberties' website at: https://www.justice.gov/opcl/doj-systems-records#OPA.

By signing the attached form, you consent to allowing the Office of the Pardon Attorney to obtain information regarding your citizenship and/or immigration status from the courts, from other government agencies, from other components within the Department of Justice, and from the Department of Homeland Security, U.S. Citizenship and Immigration Services (DHS-USCIS), Systematic Alien Verification for Entitlements (SAVE) program. The information received from these sources will be used for the sole purposes of determining an applicant's qualification for a Certificate of Pardon under the October 6 proclamation and for record-keeping of those determinations. Further, please be aware that if the Office of the Pardon Attorney is unable to verify your citizenship or immigration status based on the information provided below, we may contact you to obtain additional verification information. For more information regarding the DHS-USCIS's SAVE program and its ordinary uses, please visit its website at: https://www.uscis.gov/save.

Your disclosure of information to the Office of the Pardon Attorney on this form is voluntary. If you do not complete all or some of the information fields in this form, however, the Office of the Pardon Attorney may not be able to effectively respond. Information regarding gender, race, or ethnicity is not required and will not affect the processing of the application.

Application Form on page 2.

Page 1 of 3

United States Department of Justice Office of the Pardon Attorney

Washington, D.C. 20530 January 2023

OMB Control No: 1123-0014

APPLICATION FOR CERTIFICATE OF PARDON FOR SIMPLE POSSESSION OF MARIJUANA

Complete the following:

Name:

(first) (middle) (last)

Name at Conviction:

(if different) (first) (middle) (last)

Address:

(number) (street) (apartment/unit no.)

(city)

________________

Email Address:

(state) (Zip Code)

__________________

____________________

Gender: _ Ethnicity: _

Race:

Date/Place of Birth:

(date of birth) (place of birth)

Alien Registration Number (A-Number), Certificate of Naturalization Number, or Citizenship Number (if applicant is a lawful permanent resident or naturalized citizen):

(A-Number, etc. )

1. Applicant was convicted on:

(month/day/year)

in the U.S. District Court for the

(Northern, etc.)

District of ^or

(state)

D.C. Superior Court of simple possession of marijuana, under

Docket No: and Code Section: ^{; OR}

(docket number) _{(code section)}

2. Applicant was charged with Code Section: in the U.S. District Court for the

(code section) ^{(Eastern, etc.)}

(

District of ^or

(state)

D.C. Superior Court under Docket No:

(Docket Number)

Page 2 of 3

United States Department of Justice Office of the Pardon Attorney

Washington, D.C. 20530 January 2023

OMB Control No: 1123-0014

APPLICATION FOR CERTIFICATE OF PARDON FOR SIMPLE POSSESSION OF MARIJUANA

With knowledge of the penalties for false statements to Federal Agencies, as provided by 18

U.S.C. § 1001, and with knowledge that this statement is submitted by me to affect action by the U.S. Department of Justice, I certify that:

1. I was either a U.S. citizen or lawfully present in the United States at the time of the offense;

2. I was a U.S. citizen or lawful permanent resident on October 6, 2022; and

3. I am either: ^{a U.S. citizen by birth;}

a U.S. naturalized citizen granted status on:

a lawful permanent resident granted status on:

4. The above statements, and accompanying documents, are true and complete to the best of my knowledge, information, and belief.

5. I acknowledge that any certificate issued in reliance on the above information will be voided, if the information is subsequently determined to be false.

^(date) (signature)

Page 3 of 3

United States Department of Justice Office of the Pardon Attorney Washington, D.C. 20530 January 2023