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Application For Certificate Of Relief From Disabilities Or Certificate Of Good Conduct - New York

Application For Certificate Of Relief From Disabilities Or Certificate Of Good Conduct Form. This is a New York form and can be used in General Statewide .
 Fillable pdf Last Modified 12/26/2012
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STATE OF NEW YORK DEPARTMENT OF CORRECTIONS AND COMMUNITY SUPERVISION CERTIFICATE REVIEW UNIT The Harriman State Campus ­ Building 2 1220 Washington Avenue Albany, NY 12226-2050 (518) 485-8953 In response to your recent request, attached is an application for a Certificate of Relief from Disabilities or Certificate of Good Conduct. Return the completed original application form (not a copy), w ith all signatures notarized, to the Certificate Review Unit at the above address. You must submit, with the original application, proof of payment of income taxes for the last three years. Satisfactory proof will be copies (do not sent originals ­ they will not be returned) of your federal income tax returns, plus statements of wages (W-2 Forms), and copies of all statements of Miscellaneous Income (Form 1099). If you do not have copies, you m ay contact the IR S at 1-800-829-1040, and they w ill provide you w ith transcripts. If you have received Public Assistance or Social Security for any or all of this three-year period, a printout from the agency providing you with support must be submitted, showing all benefits received. If you were convicted of a felony in a state other than New York, or in a Federal Court, you may need to be fingerprinted. You will be notified by mail if this applies to you. An investigation into your circumstances is required and will include, but not necessarily be limited to, the following: 1. Employment history and means of support 2. Proof of payment of income taxes for the last three years 3. Proof of payment of any fines or restitution After all necessary documents and records have been received, a field representative will contact you and arrange for an interview at your residence to clarify any questions and verify your current circumstances. The New York State Department of Corrections and Community Supervision will then evaluate your application to determine whether a certificate will be granted. Statute permits the Department of Corrections and Community Supervision to remove one, more than one, or all allowable disabilities. This is a lengthy process, therefore, your cooperation is essential. If, during the process, you move or change your phone number, contact this office as soon as possible. If you desire restoration of firearms privileges and were convicted of a felony in Federal Court, you must seek relief from the Bureau of Alcohol, Tobacco and Firearms. If you were convicted of a felony in another state, you must seek relief from that state for restoration of firearms privileges. Rev. 11/2012 American LegalNet, Inc. www.FormsWorkFlow.com IMPORTANT INFORMATION (Detach and retain for your records) Granting of a Certificate removes disabilities you incurred but does not remove the underlying conviction. Neither does it limit a prospective employer or licensing agency from exercising lawful discretion to refuse employment, or to refuse to grant or renew any license, permit, or privilege. The information below is for your guidance in determining your eligibility and the authority to which you should apply. For more specific information, consult Article 23 (Sections 700-706) of New York State Correction Law. I. Eligibility A. B. CERTIFICATE OF RELIEF FROM DISABILITIES: An eligible offender is one who has been convicted of any number of misdemeanors and up to one felony. CERTIFICATE OF GOOD CONDUCT: This certificate is reserved for an individual who has been convicted of two or more separate felonies or an individual seeking the removal of a disability pertaining to a specific public office. One must have demonstrated a minimum period of good conduct in the community. The statutory waiting period is five years (if the highest felony on your criminal history record is an A or B) or three years (if the highest felony on your criminal history record is a C, D or E) or one year (if you have only misdemeanors on your criminal history record). The waiting period begins at the time of your last release from incarceration to community supervision, or discharge from incarceration by maximum expiration, or your last criminal conviction (which ever comes later). II. Issuing Authority (who to apply to) A. CERTIFICATE OF RELIEF FROM DISABILITIES: The sentencing court is the issuing authority in all instances except where a conviction: 1. 2. results in commitment to a New York State correctional facility, or was in a federal court or court of another state and the applicant is presently a resident of New York State. Certificates in these cases shall be issued by the New York State Department of Corrections and Community Supervision. B. CERTIFICATES OF GOOD CONDUCT: Only the Department of Corrections and Community Supervision is authorized to issue this certificate. Determine which certificate you are eligible for and submit your application to the appropriate issuing authority. An investigation into your circumstances is required. Sentencing Court Consult the local telephone directory for address NYS Department of Corrections and Community Supervision State of New York Department of Corrections and Community Supervision Certificate Review Unit The Harriman State Campus ­ Building 2 1220 Washington Avenue Albany, NY 12226-2050 Rev. 11/2012 American LegalNet, Inc. www.FormsWorkFlow.com Rev. 11/2012 NEW YORK STATE DEPARTMENT OF CORRECTIONS AND COMMUNITY SUPERVISION CERTIFICATE REVIEW UNIT 1. Purpose for the certificate (be specific): _________________________________________ _________________________________________________________________________ IDENTIFYING 2. 3: 5. 6. Name: ___________________________________________________________________ (Last) (First) (Middle) (Jr., Sr.) Date of Birth: ___________________ Sex: ( ) Male ( ) Female ( ) Native American ( ( ) Caucasian ( ) Other 4: Birth Place __________________ (City, State) Race: ( ( ) African/American ) Chinese ( ) Hispanic ) Japanese 7. 8. 12. Social Security Number: _______ - _______ - _______ Height: _______ 9. Weight: _______ 10. Eye Color: _______ 11. Hair Color: ________ Have you ever been known by any other name? If yes, indicate below and state reason(s) for change of name. Name: ______________________________ ______________________________ Reason for Change of Name: _________________________________ _________________________________ RESIDENCE 13. Present Address: _________________________________________________________________________ (Street) (City) (State) (Zip Code) _______________________________
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