Marijuana Application Form_pdf

OMB Control No: 1123-0014

APPLICATION FOR CERTIFICATE OF PARDON FOR
SIMPLE POSSESSION OF MARIJUANA
On October 6, 2022, President Biden issued a presidential proclamation that pardons
federal convictions for simple marijuana possession offenses.

How a pardon can help you
A pardon is an expression of the President’s forgiveness. It does not signify innocence or expunge the
conviction. But it does remove civil disabilities—such as restrictions on the right to vote, to hold
office, or to sit on a jury—that are imposed because of the pardoned conviction. It may also be helpful
in obtaining licenses, bonding, or employment.

You qualify for the pardon if:
•

•
•

On or before October 6, 2022, you were charged with or convicted of simple possession of marijuana
by either a federal or D.C. Superior court
You were a U.S. citizen or lawfully present in the United States at the time of the offense
You were a U.S. citizen or lawful permanent resident on October 6, 2022

Request a certificate to show proof of the pardon
A Certificate of Pardon is proof that you were pardoned under the proclamation. The certificate is the only
documentation you will receive of the pardon. Use the application below to start your request.

What you'll need for the request
About you
You can submit a request for yourself or someone else can submit on your behalf. You must
provide personal details, like name or citizenship status and either a mailing address, an email
address or both to contact you. We strongly recommend including an email address, if available, as
processing times may be greater without email. You can also use the mailing address or email
address of another person, if you do not have your own.
About the charge or conviction
You must state whether it was a charge or conviction, the court district where it happened, and the
date (month, day, year). If possible, you should also:
•
•

enter information about your case (docket or case number and the code section that was
charged)
upload your documents
o charging documents, like the indictment, complaint, or criminal information; or
o conviction documents, like the judgment of conviction or the court docket sheet
showing the sentence and date it was imposed

Without this information, we can't guarantee that we'll be able to determine if you qualify for the pardon under
the proclamation.

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

OMB Control No: 1123-0014

APPLICATION FOR CERTIFICATE OF PARDON FOR
SIMPLE POSSESSION OF MARIJUANA
Instructions:
An online version of this application is available at: Presidential Proclamation on Marijuana Possession
(justice.gov). You can also 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 NW, Washington, DC 20530.
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 3.
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United States Department of Justice
Office of the Pardon Attorney
Washington, D.C. 20530 February 2023

OMB Control No: 1123-0014

APPLICATION FOR CERTIFICATE OF PARDON FOR
SIMPLE POSSESSION OF MARIJUANA
Complete the following:
Name:

(first)

Name at Conviction:
(if different)

Address:

(first)

(number)

(middle)

(last)

(middle)

(last)

(street)

(city)

(apartment/unit no.)
(state)

(Zip Code)

Email Address: _______________________________________
Gender: ___________________________
Race:

Phone Number: _________________________
Yes

Are you Hispanic or Latino?:
Asian

Alaska Native or American Indian
Native Hawaiian or Other Pacific Islander

No

Black or African American
White

Other

Citizenship or Residency Status:
U.S. citizen by birth
U.S. naturalized citizen

Date Naturalization Granted:

Lawful Permanent Resident

Date Residency Granted:

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: __________________ in the U.S. District Court for the _____________
(month/day/year)

District of _____________ or
(state)

(Northern, etc.)

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)

District of _______________ or
(state)

(Eastern, etc.)

D.C. Superior Court under Docket No: ______________________
(docket number)

_______________________________________________________________________________________________________________
Page 3 of 4

United States Department of Justice
Office of the Pardon Attorney
Washington, D.C. 20530 February 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. The applicant was either a U.S. citizen or lawfully present in the United States at the time of the

offense.

2. The applicant was a U.S. citizen or lawful permanent resident on October 6, 2022.
3. The above statements, and accompanying documents, are true and complete to the

best of my knowledge, information, and belief.

4. 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 4 of 4
United States Department of Justice
Office of the Pardon Attorney
Washington, D.C. 20530 February 2023