Form Dpca-52 - Application By An Eligible Offender For A Certificate Of Relief From Disabilities

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STATE OF NEW YORK
FOR COURT OR BOARD OF PAROLE
APPLICATION BY AN ELIGIBLE OFFENDER FOR
Docket, File or other Identifying No.
A CERTIFICATE OF RELIEF FROM DISABILITIES
1. Applicant’s Last Name
First Name
Middle Initial
3. NYSID Number (If known)
2. Address (Street and No., City, State, Zip Code)
4. Sex
5. Race
6. Height
7. Date of Birth
Male
Female
feet
inches
8. Crime or Offense for which Convicted
9. Date of Arrest
10. Date of Sentence
11. Court of Sentence (Court, Part, Term, Venue)
12. Certificate Requested from:
a.
Court Indicated in No. 11
b.
State Board of Parole
13. If certificate being applied for is intended to replace an
existing certificate, enter issue date of original certificate.
Date:
Not Applicable
14. Application is hereby made for a grant of a “CERTIFICATE OF RELIEF FROM DISABILITIES” which will:
a.
Relieve the holder of all forfeitures, and of all disabilities and bars to employment, excluding the right to retain or
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 to employment hereinafter enumerated
15. The applicant agrees to allow an investigation to be made to determine his/her fitness for a certificate of relief from
disabilities, pursuant to Art. 23, Correction Law.
Applicant’s Signature
Date
State of New York
16.
County of
being duly sworn, deposes and says that he/she is the applicant named
in the within application; that he/she has read the foregoing application and knows the contents thereof; that the same is
true to his/her own knowledge, except as to the matters therein stated to be alleged on information and belief, and that as to
those matters he/she believes it to be true.
Sworn to before me this
day of
,
Signed
DPCA-52 (4/04)
Page 1 of 1

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