Form Dc- Dpca-52 - Application By An Eligible Offender For Certificate Of Relief From Disabilities Page 2

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This page is filled based on the information
FOR COURT OR BOARD OF PAROLE
STATE OF NEW YORK
from the application (page 1) - Submit this
Docket, File or other Identifier
CERTIFICATE OF RELIEF FROM DISABILITIES
proposed certificate with the Application.
This certificate is issued to the holder from all or certain enumerated disabilities, forfeitures, or bars to his employment
automatically imposed by law by reason of his conviction of the crime or of the offense specified herein.
This certificate shall NOT be deemed nor constructed to be a pardon.
See reverse side for explanation of the law governing this certificate, or
The original certificate is to be presented to the person to whom awarded. One copy is to be retained by the issuing agency, and one copy is to be
filed with the NYS Division of Criminal Justice Services, 4 Tower Place, Albany, NY 12203-3702
1.
Used by DCJS
3.
NYSID
Holder of Certificate
2.
Last Name, First Name, Initial
( i f
u n k n o w n ,
s u p p l y
fingerprints to DCJS.
If
fingerprints are unobtainable,
complete 15-18 below)
4.
Crime or Offense for which convicted
5.
Date of arrest
6.
Date of sentence
7.
Court of Disposition
8.
Certificate issued by:
Court indicated in box 7
(Court, Part, Term, Venue)
State Board of Parole
9.
Date this certificate issued
10.
Certificate replaces an existing Certificate of Relief from
Disabilities, previously issued on:
Not applicable
11. This certificate shall
a.
relieve the holder of all forfeitures, and of all disabilities and bars to employm ent, excluding the right to retain
or to be eligible for public office, by virtue of the fact that the certificate is issued at the time of sentence.
b.
relieve the holder of all disabilities and bars to employment, excluding the right to be eligible for public office.
c.
relieve the holder of the forfeitures, disabilities or bars hereinafter enumerated
12.
This certificate shall be considered permanent.
This certificate shall be considered temporary until
. After this date, unless revoked
earlier by issuing court or parole board, this certificate shall be considered permanent. A person who
knowingly uses or attempts to use a revoked certificate in order to obtain or exercise any right or privilege that
he/she would not be entitled to obtain or to exercise without valid certificate shall be guilty of a misdemeanor.
13.
14.
Signature of issuing official
Name of issuing official
title of issuing official
15. Sex
16. Race
17. Height
18. Date of Birth (Month/Day/Year)
Male
Female
Ft
In.
DC- DPCA-53 (6/05) Proposed Certificate submitted with DC- DPCA-52
original
copy to file
copy to DCJS

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