Application For Certificate Of Pardon For Simple Possess

APPLICATION FOR CERTIFICATE OF PARDON
FOR SIMPLE POSSESSION OF MARIJUANA
Instructions:
If you were charged with or convicted of simple possession of marijuana by either a federal or

D.C. Superior Court and were pardoned by President Biden’s proclamation of October 6, 2022, you
may obtain an individual certificate of pardon showing that the proclamation applies to you. If you
believe that the proclamation applies to you and wish to obtain such a certificate, complete and return
this application with the required documents to [email protected] or
U.S. Department of Justice, Office of the Pardon Attorney, 950 Pennsylvania Avenue, Washington,
DC 20530.
Provide the following: (1) the charging document (the indictment, complaint, or criminal
information); and/or (2) the judgment of conviction or the court docket sheet showing the sentence
and date it was imposed. If documentation cannot be obtained to verify your charges or conviction, the
Office of the Pardon Attorney may be unable to issue you a certificate of pardon.
Note: Submit a separate form for each conviction or charge for which you are seeking a
certificate of pardon.

Privacy Act Statement:
The Office of the Pardon Attorney has authority to collect this information under the United States Constitution,
Article II, Section 2 (the pardon clause); Orders of the Attorney General Nos. 1798-93, 58 Fed. Reg. 53658 and
53659 (1993), 2317-2000, 65 Fed. Reg. 48381 (2000), and 2323-2000, 65 Fed. Reg. 58223 and 58224 (2000),
codified in 28 C.F.R. §§ 1.1 et seq. (the rules governing petitions for executive clemency); and Order of the
Attorney General No. 1012-83, 48 Fed. Reg. 22290 (1983), as codified in 28 C.F.R. §§ 0.35 and 0.36 (the
authority of the Office of the Pardon Attorney). The principal purpose for collecting this information is to
enable the Office of the Pardon Attorney to issue an individual certificate of pardon to you. The routine uses
which may be made of this information include provision of data to the President and his staff, other
governmental entities, and the public. The full list of routine uses for this correspondence can be found in the
System of Records Notice titled, “Privacy Act of 1974; System of Records,” published in Federal Register,
September 15, 2011, Vol. 76, No. 179, at pages 57078 through 57080; as amended by “Privacy Act of 1974;
System of Records,” published in the Federal Register, May 25, 2017, Vol. 82, No. 100, at page 24161.
Your disclosure of information to the Office of the Pardon Attorney on this form is voluntary. If you do not
complete all or some of the information fields in this form, however, the Office of the Pardon Attorney may not
be able to effectively respond.

Application Form on page 2.

Page 1 of 2
United States Department of Justice
Office of the Pardon Attorney
Washington, D.C. 20530
October 2022

APPLICATION FOR CERTIFICATE OF PARDON
FOR SIMPLE POSSESSION OF MARIJUANA
Complete the following:
Name: ___________________________________________________________________________
(first)

(middle)

(last)

Name at Conviction: _____________________________________________________________
(if different)

(first)

(middle)

(last)

Address: __________________________________________________________________________
(number)

(street)

(apartment/unit no.)

_____________________________________________________________________________________________________________
(city)
(state)
(Zip Code)
Select One
Email Address: _______________________________ Gender: _________
Race: _______________
Select One

Select One

Date/Place of Birth:_____________ ______________________Ethnicity: ______________
(date of birth)

(place of birth)

1. Applicant was convicted on: ______________________
(month/day/year)

the

(Eastern/Northern, etc.)

District of

in the U.S. District Court for

(state)

or (

D.C. Superior Court) of simple

possession of marijuana, under Docket No: ____________________________ and
(docket number)

Code Section: __________________; OR
(code section)

2. Applicant was charged with Code Section_______
(code section)

District of ___________ or (
(state)

in the U.S. District Court for the ___________
(Eastern, etc.)

D.C. Superior Court) under Docket No: __________________
(Docket Number)

With knowledge of the penalties for false statements to Federal Agencies, as provided by 18 U.S.C. §
1001, and with knowledge that this statement is submitted by me to affect action by the U.S. Department
of Justice, I certify that:
(1) I am currently a U.S. citizen or lawful permanent resident, and I was either a U.S. citizen or lawfully
present in the United States at the time of the offense; and
(2) The above statements, and any accompanying documents, are true and complete to the best of my
knowledge, information, and belief.

(date)

(signature)

Page 2 of 2
United States Department of Justice
Office of the Pardon Attorney
Washington, D.C. 20530 October 2022