Form NEW Application for Remission of Financial Penalties

OMB Number: XXXX-0NEW Expiration Date: XX/XX/XXXX

Application for Remission of Financial Penalties

What Is Remission and How Can It Help You?

Remission is asking the President to remove fines or restitution that a court gave you because of a federal conviction.

Remission CAN:

• Forgive the part of the penalties you have not already paid

Remission CANNOT:

• Erase a conviction

• Expunge a conviction

• Let you get back any payments or assets you have already turned over to the government

To apply, you should:

• Have a conviction under federal law, D.C. Code, or Uniform Code of Military Justice

• Have completed your term of imprisonment, if any

AND/OR

Have completed your supervised release or probation term

• Live in the U.S. or its territories

If you are still serving your sentence, use the commutation application form: justice.gov/pardon/apply-commutation. If you are seeking forgiveness, use the pardon form: justice.gov/pardon/apply-pardon.

How to Begin:

Filling out and submitting the application is the first step in a lengthy process. You will be asked to give details about yourself, your reasons for seeking remission, challenges you may be facing because of your conviction, information about your conviction and other criminal history, if any, and information about your finances.

It is not required, but it may be helpful to gather these documents, if available, before you start:

1. Presentence investigation report

This report is prepared by the U.S. Probation Office to help the court with sentencing.

2. Judgment

This document shows what sentence the court gave.

3. Statement of reasons

This document gives the court’s reasons for the sentence (not applicable in D.C. Code or military cases).

4. Indictment or Information

These documents list the charges against you.

5. Order of asset forfeiture

This document shows whether you were ordered to forfeit any property.

6. Case docket report

The docket lists all the events in the case.

7. Payment schedule with the court

This document shows the payments you have made.

WHERE CAN I FIND DOCUMENTS RELATED TO MY CONVICTION?

You may be able to get the judgment, indictment, information, and case docket report online:

Federal cases: PACER (has fees):

uscourts.gov/court-records/find-case-pacer

D.C. cases:

dccourts.gov/superior-court/cases-online

For documents that aren’t available online, you can contact or go to the court clerk’s office:

Federal court clerk’s offices:

uscourts.gov/about-federal-courts/federal-courts-public/court-website-links

D.C. Superior Court:

dccourts.gov/superior-court/criminal-division

When will the Office of the Pardon Attorney (PARDON) contact you?

The remission application process can take months or years. We ask that you keep your contact information updated, so that we can reach you when needed. Until the notification of the President’s final decision, your application is “pending” or open. Messages from PARDON during the process DO NOT predict the final decision. No outcome is guaranteed. Common situations when we may contact you include:

Confirmation

Letter

We will send an email or letter confirming your application has been received

Follow-Up Letters

We may send emails or letters asking for more information or updates

Background Investigation

We will let you know if a background investigation has been started

Notification of Final Decision

We will let you know if the President has granted or denied remission

HELPFUL TIPS

• This application asks for information to help us get a better picture of you and your life. All questions are important. Answer all questions to the best of your knowledge and ability and give as much detail as you can.

• The application asks for a large amount of personal information that may require research and collecting documents from the past. You may need several sessions to complete the application.

• To help us process your application more quickly, if an answer does not apply to you, write “Not Applicable.”

• Sending your application as a PDF by email will help us process your application more quickly.

• If you mail the application, stapling, gluing, or taping any part will slow down processing.

• If you need more space, you can add pages or documents.

Table of Contents

A. Background Information.…………………………………………………………………….6

We need to know who is applying for remission, to confirm your identity, and to be sure any background investigation is accurate.

B. Reasons for Seeking Remission………………………………………………………..…..8

We need to understand how your conviction has affected your life and what you hope the remission will change or improve.

Additional Information About Your Life Since Your Conviction (Parts C-F):

We need the questions in sections C-F (pages 9-12) to help us get a better picture of how the fine or restitution has impacted your financial situation and the challenges you may have faced because of these penalties.

C. Job History………….…………………………………………………………………………9

D. Places Lived…………………………………………………………………………………10

E. Current Information on Financial Penalties….……………………………………...…….11

F. Current Monthly Financial Information.………………………………………………...….12

G. Case Background and Other Criminal History…………………………………….........14

We need to make sure we have the correct case and understand your offense conduct. It also gives you a chance to explain any other criminal history that may appear in a background investigation.

H. Other Relevant Information………………………………………………………………...17

Optional space so you can tell us anything else you would like us to know that might strengthen your application, such as any achievements, participation in personal growth, or other ways you have spent your time or grown since your conviction

I. Certification and Personal Oath…….………………………………………………………18

We need your signature to know that you are submitting the remission application willingly and that you have answered the questions accurately, to the best of your ability.

J. Authorization for Release of Information…………………………………………………..19

The authorization lets us and any investigators get information and documentation about your life.

K. Application Checklist………………………………………………………….…………….20

This checklist will help you review your application to make sure it is complete. It also tells you where to submit the application and how to keep your contact information updated.

Know Your Rights and How Your Information Will be Used

Who is collecting this information and what are my rights?

The Office of the Pardon Attorney collects your information to review and make recommendations to the President on remission applications. The Office is part of the Department of Justice, which is a federal government agency. You have the right not to give information to us. If you do not answer some of the questions, however, we cannot guarantee that we will be able to continue working on your application.

How will my information be used under the Privacy Act.

The principal purpose for collecting this information is to enable the Office of the Pardon Attorney to process your request for remission of financial penalties. 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, and at the

U.S. Department of Justice, Office of Privacy and Civil Liberties’ website.

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 remission of financial penalties); 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).

Can the government publish my information?

If you are granted or denied remission by the President, your name will be released, including on our website or in response to public information requests, in accordance with our Freedom of Information Act obligations. Non-public documents, such as this petition and supporting documents, the presentence investigation report, the results of any federal background investigation, and the recommendation of the Department of Justice, are not generally available under the Freedom of Information and Privacy Acts. However, the Pardon Attorney may disclose the contents of remission files in the possession of the Department of Justice when the disclosure is required by law or the ends of justice. Additionally, this office would confirm that a specific individual has applied for or was granted or denied remission.

The President and his immediate staff are not subject to the constraints of the Freedom of Information and Privacy Acts. Accordingly, while remission-related documents in the possession of the White House traditionally have not been made public, they may be legally disclosed at the discretion of the President. In addition, remission-related documents retained by the White House at the end of a presidential administration will become part of the President’s official library, where they become subject to the disclosure provisions of the Presidential Records Act..

Answer questions as accurately and as fully as you can, to the best of your knowledge.

Making any intentionally false statements of material facts may be a reason for denying your petition. In addition, the knowing and willful falsification of a document submitted to the government may subject you to criminal punishment, including up to five years’ imprisonment and a $250,000 fine. See 18 U.S.C. §§ 1001 and 3571.

Public Burden Statement

This collection meets the requirements of 44 U.S.C. § 3507, as amended by the Paperwork Reduction Act of 1995. We estimate that it will take 180 minutes to read the instructions, gather the relevant materials, and answer questions on the form. Send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to Attn: Office of the Pardon Attorney, U.S. Department of Justice, Attn: OMB Number XXXX-XXXX, RFK Building, 950 Pennsylvania Avenue, N.W., Washington, D.C. 20530. The OMB clearance number, XXXX-XXXX, is currently valid. PARDON may not collect this information, and you are not required to respond, unless this number is displayed.

Note: Nothing in this application or instructions is legal advice.

A. Background Information

a. Applicant information

Full name:

First name

Middle name (if you have one)

Last name

If different, full legal name at time of conviction:
First name	Middle Name (if you have one)		Last name

Other names (married, maiden, aliases, etc.)

Social security number

Date of birth (Month, Day, Year)

Country where you were born

City and state where you were born

Parent #1’s full name (including maiden name)	Citizenship:	☐ U.S. citizen by birth ☐ U.S. naturalized citizen
Parents #2’s full name (including maiden name)		☐ Other nationality

b. Contact information

Street address

Apartment/Unit

City, State

Zip code

Email is the best way to contact you. If you do not have email, you can give the email of a person you trust, or your phone number. If an attorney is helping you, give their information

:

Your email address or email of a trusted person				Phone number
Attorney’s name		Attorney’s email address and phone number

c. Previous applications

Have you applied for federal commutation or pardon before?

☐ Yes ☐ No

Date applied (month/year): Date of decision (month/year):

d. Gender and race. This information is for statistical data collection purposes:

What is your race and/or ethnicity? Select all that apply. ☐ American Indian or ☐ Asian ☐ Black or Alaska Native African American ☐ Hispanic or Latino ☐ Middle Eastern or ☐ Native Hawaiian or North African Pacific Islander ☐ White

Gender identity ☐ Female ☐ Male ☐ Other

e. Family information. For this section, it would be helpful to have dates for:

• Your marriage (if applicable)

• Your divorce (if applicable)

• Your children’s birth dates (if applicable)

Current marital status ☐ Civil union/domestic partnership ☐ Divorced ☐ Married ☐ Never Married ☐ Separated ☐ Widowed	Current spouse / partner information, if applicable:
	Spouse / partner name
	Date of marriage or civil union/domestic partnership
	Place of marriage or civil union/domestic partnership
Child or dependent information, if applicable:

Full name of child or dependent	Date of birth	Name(s) of other parent(s)	Do you have custody? (Y/N)

☐ Check here if you are attaching additional pages. Add the section name to the top of each page.

B. Reasons for Seeking Remission

What are your reasons for seeking remission?

The more specific you can be, the better. Feel free to use the space below and/or attach additional pages.

You may want to include:

• How your life would change if granted remission

• Challenges that you have faced because of your fine or restitution

  • Are there things having a fine or restitution prevent you from doing?

  • Are there ways the fine or restitution create significant burdens for you?

☐ Check here if you are attaching additional pages. Add the section name to the top of each page.

C. Job History

Where have you worked in the last seven years?

• Include full and part-time jobs

• If applicable, include jobs while incarcerated

• Use approximate dates

• Do not leave any gaps in dates

• If you have had more than three jobs, attach additional pages

• If you are retired, give the approximate date your retirement began in the “Current employer” section

Current employer

Type of business

Position

Month/year started

Employer street address

City, state

Zip code

Supervisor name and phone number

Previous employer name	Type of business	Position	Employer address and phone number	Approximate dates worked (month/year to month/year)

If you are currently unemployed or have been in the past, give the dates and share how you supported yourself during that time:

If your criminal record has affected your ability to find work, give details here. If you received a rejection letter or termination notice due to your conviction, you may attach a copy.

Your work history will be reviewed as part of any background investigation. If you have been fired, accused of misconduct at a job, or given an unsatisfactory job performance rating, give details here.

☐ Check here if you are attaching additional pages. Add the section name to the top of each page.

D. Places Lived

Where have you lived in the last three years?

We already have your current address from your background information.

• Do not use P.O. Boxes.

• Give apartment/unit numbers.

• Do not leave any gaps in dates.

If there were any periods where you did not have housing, you can note that below.

Street address	Apartment /Unit	City, state	Zip code	Approximate dates living there (month/year to month/year)

If you are experiencing homelessness or have in the past, note the dates.

(month/year to month/year)

☐ Check here if you are attaching additional pages. Add the section name to the top of each page.

E. Current Information on Fine or Restitution

Tell us about your fine or restitution and payment history.

Financial penalties:

Assessment amount

Fine amount

Restitution amount

Do you share responsibility for restitution with another person(s) (are you jointly and severally responsible for payment)?	☐ Yes	☐ No	☐ Unsure
If yes, have the others been making payments?	☐ Yes	☐ No	☐ Unsure
Are you on a payment schedule?	☐ Yes	☐ No

Payment schedule: $ per Date of last payment:

(week, month, year, etc.)

Have you been making your scheduled payments?	☐ Yes	☐ No
If no, have you been making any payments?	☐ Yes	☐ No

If you are not making payments or are making payments that are less than the amount required, explain why:

Date started making payment:

Total payments made to date: $

Amount of fine or restitution remaining: Principal amount: $

Interest owed: $

Attach records of payment history or most recent payment, if available.

Did the court order you to forfeit any assets or money? ☐ Yes ☐ No

If yes, attach a list of affected property.

☐ Check here if you are attaching additional pages. Add the section name to the top of each page.

F. Current Monthly Financial Information

Give details on your income, assets, liabilities, and monthly expenses.

We know that financial penalties from criminal convictions can make it harder to keep up with necessary expenses. We know this can be a hard subject to discuss. Your honest reflection is helpful to us.

• Give approximate dates and amounts, to the best of your ability.

a. Income

Monthly Job earnings (amount in paycheck):	$
Child Support Received	$
Government Benefit (total benefit received): Types (if multiple types use additional pages):	$
Other benefits received: Specify source:	$
Total	$

b. Assets

Include below all cash on hand, bank accounts, securities, money owed to you by others, life insurance, safe deposit boxes or storage facilities, motor vehicles, real estate, mortgage loans owed to you, other assets, anticipated assets, and business holdings. Include assets for yourself, your spouse or significant other, and any dependent.

Type of Asset	Location of Asset (for example, bank name)	Fair Market or Actual Value
		$
		$
		$
		$

Include below all assets transferred or sold since your conviction with a cost or fair market value of more than $500.00, or assets that someone else is holding on your behalf.

Type of Asset	Date Transferred or Sold	Fair Market or Actual Value
		$
		$

☐ Check here if you are attaching additional pages. Add the section name to the top of each page.

c. Liabilities:

List all liabilities, including charge accounts, lines of credit, mortgage balances, medical debts, child support owed, other debts, civil suits, and bankruptcy filings.

Description of Liabilities	Amount
	$
	$
	$
	$
	$

d. Necessary Monthly Living Expenses:

List all expenses, including rent, utilities, cell phone payments, groceries, goods, services, , credit card payments, insurance (health insurance, homeowner’s insurance, car insurance, etc.), car payments, transportation, home repairs, mortgage, student loan payments, etc.

Description of Liabilities	Amount
	$
	$
	$
	$
	$
Total Monthly Expenses	$

Is there anything else you would like to share about your experience with finances since your conviction?

☐ Check here if you are attaching additional pages. Add the section name to the top of each page.

G. Case Background and Other Criminal History

a. Give basic information on the conviction for which you are seeking remission.

If you are seeking remission of financial penalties for more than one conviction or set of offenses, attach additional pages.

It is not required, but, if available, sending a copy of these documents with your application will help us review your case more quickly. See cover page for more information.

• Presentence report

• Judgment

• Statement of reasons

• Order of asset forfeiture

• Indictment or Information

• Case docket report

☐ Check here if you are attaching any of these documents

Did you plead guilty?

☐ Yes

☐ No

Approximate date(s) of offense (month/year to month/year)		Approximate date you were sentenced (month/year)
Court where you were prosecuted (D.C. Superior Court or name of U.S. District Court)				Case number

Of what were you convicted?

What sentence did you receive? (fill in where applicable)

Imprisonment:	Prison sentence (months or years)		Approximate date you were released from prison, community confinement, or home detention (month/year)
Probation or supervised release:	Sentence for probation or supervised release (months or years)		Approximate date you completed your term of probation or supervised release (month/year)

Financial penalties:	Assessment amount			Fine amount		Restitution amount
Assets or money forfeited:

b. Tell us about your conduct for which you were convicted.

We want to hear from you, in your own words. The more specific and complete you are, the more helpful it is to us. We are specifically looking for information that is NOT in the public record of your case. You may wish to answer the following:

• What was your role in the offense?

• How, when, and why did you get involved?

• What actions did you take in connection with the offense? (Include all actions, even if you pleaded guilty to only specific conduct, counts, or portions of the full criminal activity.)

Do you accept responsibility for your conduct? Explain why or why not.

.

☐ Check here if you are attaching additional pages. Add the section name to the top of each page.

c. Tell us about any other criminal history.

Your criminal history will be reviewed as part of any background investigation. List any other arrests or convictions that may appear on your criminal history record, if any, including juvenile and expunged records, and give any information you would like us to know about them. If you have your presentence report, you may attach it and give missing or additional information you would like us to know below.

☐ Check here if you are attaching additional pages. Add the section name to the top of each page.

H. Other Relevant Information – OPTIONAL

If there is any information you feel would make your application stronger, include it in additional pages. You can tell us about:

• Achievements, like physical fitness training or accomplishments;

• Participation in personal growth, like counseling, therapy, or meditation; or

• Other ways you have spent your time that tell us about who you are today.

This is entirely optional, and it will not be held against you if you choose not to use this page.

☐ Check here if you are attaching additional pages. Add the section name to the top of each page.

I. Certification and Personal Oath

I certify, under penalty of perjury, that all information in my petition and any document submitted with it were given or authorized by me and that I reviewed and understand the information contained in, and submitted with, my petition. I further certify, under penalty of perjury, that all the information I gave in the application is complete, true, and correct to the best of my knowledge, information, and belief.

In petitioning the President of the United States for remission of financial penalties, I do solemnly swear that I will be law-abiding and will support and defend the Constitution of the United States against all enemies, foreign and domestic, and that I take this obligation freely and without any mental reservation whatsoever.

Respectfully submitted this day of , .

Day Month Year

Your signature

J. Authorization for Release of Information

Carefully read this authorization, and if you agree, sign and date in ink.

I authorize any investigator, special agent, or other duly accredited representative of the Federal Bureau of Investigation, the Department of Defense, and any other authorized Federal agency, to obtain any information relating to my activities from schools, residential management agents, employers, criminal justice agencies, retail business establishments, courts, or other sources of information. This information may include, but is not limited to, my academic, residential, achievement, performance, attendance, disciplinary, employment history, criminal history, arrest, conviction, including the presentence investigation report, if any, medical, psychiatric/psychological, health care, and financial and credit information.

I understand that, for financial or lending institutions and certain other sources of information, a separate specific release may be needed (pursuant to their request or as may be required by law), and I may be contacted for such a release at a later date.

I further authorize the Federal Bureau of Investigation, the Department of Defense, and any other authorized Federal agency, to request criminal record information about me from criminal justice agencies for the purpose of determining my suitability for a government benefit.

I authorize custodians of records and sources of information pertaining to me to release such information upon request of the investigator, special agent, or other duly accredited representative of any Federal agency authorized above regardless of any previous agreement to the contrary. I understand that the information released by records custodians and sources of information is for official use by the Federal Government only for the purposes of processing my application for a government benefit, and may be redisclosed by the Government only as authorized by law.

Copies of this authorization that show my signature are as valid as the original release signed by me. If not previously revoked in writing, this Authorization is valid and shall remain in effect so long as I am under consideration for a government benefit.

Signature (sign in ink)
Full Name (type or print legibly)		Date Signed
Other Names Used
Street Address
City	State	ZIP Code
Home Telephone Number (include area code)	Social Security Number

K. Application Checklist

1. Gather the following information.

Required

☐ Application form (pages 6-17)

☐ Signed certification and personal oath page (page 18)

☐ Signed and completed Authorization for Release of Information form (page 19)

Optional

☐ Official records: presentence report, judgment, statement of reasons, indictment or information, order of forfeiture, court docket record, payment schedule with the court.

☐ Personal records supporting application answers

☐ Additional pages to complete application answers

2. Submit your application.

NOTE: Keep a copy of everything you submit for your personal records

The fastest way to submit your application is by email. If you send it by mail, it may take longer to process.

By email

Email documents in PDF or Word format to [email protected]

By mail

U.S. Dep’t of Justice, Office of the Pardon Attorney

950 Pennsylvania Avenue, N.W.

Washington, D.C. 20530

3. Keep your contact information updated.

We will need to reach you during the remission process. If your contact information changes, email us at [email protected] or send a letter to our mailing address.

The application process:

1. Confirmation letter: We will send an email or letter letting you know we received your application and if it is missing any parts. If you have not received a confirmation after three months, email [email protected] (preferred) or send a letter to our mailing address. You can check the status of your case on the Pardon Attorney’s website, at: https://www.justice.gov/pardon/search-clemency-case-status.

2. Follow-up letters: It may take some time for review of your application to start. During the review, we may need more information or updates to your application. If we do, we will contact you by email (preferred) or mail.

3. Background investigation: During the review of your application, a background investigation may be necessary. The investigation is conducted by agents of the Federal Bureau of Investigation (FBI). We will let you know by email (preferred) or mail if we have requested a background investigation. It may include interviews of you, neighbors, former and present employers, and other individuals who may be able to give relevant information about you. The agent will be discreet and make reasonable efforts not to disclose the reason for the investigation, but we cannot guarantee that those interviewed will not learn that you are seeking remission of financial penalties for a past criminal conviction.

4. Notification of final decision: You will be notified when a final decision is made by the President. This may take years. No hearing will be held and there is no appeal from the President’s decision to deny a request for remission of financial penalties.

5. Reapply: If your remission request is denied, you may reapply one year after the date of the denial.

United States Department of Justice, Office of the Pardon Attorney, Washington D.C. / July 2024 Page 3 of 21