Dd Form 2715-3 - Prisoner Restoration/return To Duty, Clemency And Parole Statement

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REPORT DATE

(YYYYMMDD)

PRISONER RESTORATION/RETURN TO DUTY, CLEMENCY AND PAROLE STATEMENT

(Read Privacy Act Statement before completing form.)

2. DoD ID/SSN

1. NAME

(Last 4 only)

(Last, First, Middle)

3. CORRECTIONAL FACILITY

SECTION I - RESTORATION/RETURN TO DUTY

I REQUEST SUSPENSION OF THE DISCHARGE/DISMISSAL ADJUDGED BY COURT-MARTIAL IN MY CASE, AND RESTORATION.

I understand that any unsatisfactory conduct on my part may violate the probation and vacation of suspension could result in execution of the

remainder of the court-martial sentence in addition to further disciplinary action.

I DO NOT REQUEST TO BE RESTORED/RETURNED TO DUTY.

SECTION II - CLEMENCY

I HEREBY WAIVE MY RIGHT TO BE CONSIDERED FOR CLEMENCY.

a. I understand my case will not be reviewed administratively for remission, mitigation, or suspension of the unexecuted parts of my

sentence. I further understand that I will not receive consideration for annual clemency until one year after my current clemency board

date.

b. I also acknowledge that if my sentence includes an unsuspended punitive discharge or dismissal:

(1) I may be ineligible for many or all benefits as a veteran under both Federal and state laws.

(2) I may expect to encounter substantial prejudice in civilian life.

(3) This waiver will remain part of my permanent military service record.

(4) I may not reenlist without special permission (enlisted members only).

7. I HEREBY REQUEST TO BE CONSIDERED FOR CLEMENCY IN THE FOLLOWING FORM(S):

Reduction in length of sentence.

Reduction or remission of forfeitures.

Reduction or remission of fine.

Substitution of administrative discharge for punitive discharge.

(Note: Does not apply to Air Force prisoners.)

Remission of dismissal

(officers and cadets only)

Mitigation of a DD to a BCD.

Restoration to pay grade

Restoration of precedence

(officers only)

8. MY REASON(S) FOR REQUESTING CLEMENCY ARE AS FOLLOWS:

9. PRISONER/SUPERVISEE SIGNATURE

10. WITNESS SIGNATURE

11. DATE

(YYYYMMDD)

CERTIFICATION TO BE COMPLETED FOR CLEMENCY WAIVER ONLY

12. CERTIFIED: I certify that the above individual signed this waiver in my presence, and that his/her right to request clemency and the effect of this

waiver have been fully explained to him/her.

a. CERTIFYING OFFICIAL

c. DATE

b. SIGNATURE OF CERTIFYING OFFICIAL

(Name, Grade and Title)

(YYYYMMDD)

DD FORM 2715-3, MAR 2013

Page 1 of 2 Pages

PREVIOUS EDITION IS OBSOLETE.

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