X hits on this document

9 views

0 shares

0 downloads

0 comments

4 / 4

, not related by blood or marriage, who support your pardon and attach a signed, recently dated statement from each that sets forth their support for your pardon. These people will be contacted concerning your pardon application.

Name

Address

City/State

Phone Number(s)

G

I have been discharged from probation supervision and any or all restitution and collection fees have been paid in full.

G

I have been discharged from my sentence without having been on probation or parole and any or all restitution and collection fees have been paid in full.

G

I am a parolee and have successfully completed five years under supervision and any or all restitution and collection fees have been paid in full.

G

I have been discharged after successfully completing my maximum parole period and any or all restitution and collection fees have been paid in full.

G

I am an inmate not presently eligible for parole and can produce evidence comprising the most extraordinary circumstances. (Attach a list of the most extraordinary circumstances and the supporting evidence.) Inmates who passed their first parole eligibility date should not apply.

[check appropriate box]

G

I was previously considered for pardon and rejected on

_____________________________________________________ Date

.

G

I, the applicant have attached certified statements from the appropriate authority reflecting that any and all restitution and collection fees have been paid in full.

To Whom It May Concern: I hereby authorize any agent or other authorized representative of the South Carolina Department of Probation, Parole and Pardon Services bearing

this release. or copy thereof. within one year of its date, to obtain any information in your files pertaining to my grievance records. employment, military, credit. medical or educational records including, but not limited to, academic. job performance, achievement, attendance. athletic. personal

history and disciplinary records. I hereby direct you to release such information upon request of the bearer. This release is executed with full knowledge and understanding that the information will be used in connection with my pardon investigation by the bearer and will be disseminated to those individuals or agencies directly involved in this pardon determination or to fulfill other obligations imposed by law, regulation or executive order. I hereby release you, as the custodian of such records, and any school. college, university or other educational institution, hospital, or other repository of

medical records, credit bureau, consumer reporting agency, personnel, both individually and collectively, from any and all liability for damages of

whatever kind, which may at any time result to me, my heirs, my family or associates because of compliance with this authorization and request to release information, or any attempt to comply with this release. A photocopy of this release shall be treated as an original. Should there be any

question as to the validity of this release. you may contact me as indicated below.

Full Name [Signature]

Full Name [Printed]

Social Security #

Date

Daytime Phone #

Evening Phone #

(Required by all applicants, seal required if out of state)

Street

Sworn to me this _____________ day of Full Name [Signature]

__________________,________________

.

Full Name [Printed]

City

State

Zip Code

My commission expires:

You are hereby advised the information contained on the pardon application will be verified. If any of it is of a sensitive nature which might lead to the damaging of your current status (such as contacting neighbors, employers. etc.) please advise in order that appropriate steps may be taken to minimize this risk. NOTE: If applying on behalf of someone else, indicate your authority to file this application.

Signature

Date

Form 1118 (Template) (rev. 6/17/2011)

Page 4 of 4

Document info
Document views9
Page views9
Page last viewedThu Dec 08 16:48:06 UTC 2016
Pages4
Paragraphs112
Words1676

Comments