PRISONER RESTORATION/RETURN TO DUTY, CLEMENCY AND PAROLE STATEMENT
(Read Privacy Act Statement before completing form.)
2. DoD ID/SSN
(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
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
8. MY REASON(S) FOR REQUESTING CLEMENCY ARE AS FOLLOWS:
9. PRISONER/SUPERVISEE SIGNATURE
10. WITNESS SIGNATURE
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
b. SIGNATURE OF CERTIFYING OFFICIAL
(Name, Grade and Title)
DD FORM 2715-3, MAR 2013
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