CONVICTION HISTORY. Most Recent Qualifying Conviction. (A) Offense. (B) Type of Sentence or Disposition

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1 ATTORNEY OR PARTY WITHOUT ATTORNEY (Name & Address): FOR COURT USE ONLY Telephone No: Address (Optional): ATTORNEY FOR (Name): Fax No (Optional): Bar No: SUPERIOR COURT OF CALIFORNIA, COUNTY OF ORANGE CENTRAL JUSTICE CENTER 700 CIVIC CENTER DRIVE WEST POST OFFICE BOX SANTA ANA, CA In the Matter of the Application of Type Petitioner s full name First Middle Last and Suffix, if applicable Date of Birth: CII Number: Criminal Case Number(s): (Penal Code et seq) To the Superior Court of California, County of Orange: CASE NUMBER: M - The above-named petitioner represents and shows that: CONVICTION HISTORY [All qualifying convictions must be listed If you have more than three (3) qualifying convictions, attach additional sheets following the same format] Most Recent Qualifying Conviction on case number: in the County of, California Sentenced to state prison, but execution of sentence was suspended and petitioner was placed on probation Imposition of sentence was suspended and petitioner was placed on probation Page 1 of 5 Form: L-4081 [Rev July 15, 2011] Penal Code, and

2 (date) (date) on (date) Released on probation (if no jail sentence was imposed) on (date) Pen Code History (For Probationers Only) a) After termination of probation on, a petition for relief under Penal Code section was granted on (date) after his/her Penal Code section petition was granted? Yes No c) If yes, when and where? Second Most Recent Qualifying Conviction on case number: in the County of, California Sentenced to state prison, but execution of sentence was suspended and petitioner was placed on probation Imposition of sentence was suspended and petitioner was placed on probation Page 2 of 5 Form: L-4081 [Rev July 15, 2011] Penal Code, and

3 (date) (date) on (date) Released on probation (if no jail sentence was imposed) on (date) Pen Code History (For Probationers Only) a) After termination of probation on, a petition for relief under Penal Code section was granted on (date) after his/her Penal Code section petition was granted? Yes No c) If yes, when and where? Third Most Recent Qualifying Conviction on case number: in the County of, California Sentenced to state prison, but execution of sentence was suspended and petitioner was placed on probation Imposition of sentence was suspended and petitioner was placed on probation Page 3 of 5 Form: L-4081 [Rev July 15, 2011] Penal Code, and

4 (date) (date) on (date) Released on probation (if no jail sentence was imposed) on (date) Pen Code History (For Probationers Only) a) After termination of probation on, a petition for relief under Penal Code section was granted on (date) after his/her Penal Code section petition was granted? Yes No c) If yes, when and where? RESIDENCY HISTORY I am now a resident of the State of California, and I have continuously resided in the State of California from, to the present date I currently reside in the County of at the following address: Page 4 of 5 Form: L-4081 [Rev July 15, 2011] Penal Code, and

5 PETITIONER S DECLARATION During the period of my rehabilitation, I have lived an honest and upright life, conducted myself with sobriety and industry, and exhibited good moral character I have conformed to and obeyed all the laws of the land I request that the Court make its order declaring that I have been rehabilitated; and for a Certificate of Rehabilitation recommending that the Governor of the State of California grant me a full pardon I declare under penalty of perjury under the laws of the State of California that the foregoing information is true and correct Date SIGNATURE OF PETITIONER TYPE OR PRINT NAME OF PETITIONER Page 5 of 5 Form: L-4081 [Rev July 15, 2011] Penal Code, and