Clean Slate Form

Applying for the CLEAN STATE Program:

How would you like to be updated regarding your application? *

Email Text Message

Applicant’s Information

Please be advised that an attorney may need to send you official documents in mail or call you to provide additional assistance with your case, therefore, provide details correctly as possible and all fields are mandatory.

Personal Information:

Last Name: *

First Name: *

Middle Name:

Aliases or in your record:

Date of Birth: *

Citizenship Status: *

Marital Status: *

Driving License or ID Number: *

Last 4 digits of Social Security Number: *

Contact Information:

Mailing Address

Street: *

City: *

State: *

Zip Code: *

Phone Number: *

Alternative Phone Number:

Email Address: *

Case Information (if known):

Fill in as much information as you can, do not be discouraged if you do not know the answers. We will aid according to your records.

Do you have a copy of your criminal history record from the Department of Justice?

Case Number: (if information is available)

Are you currently being charged with a crime?

If yes, are you being charged as an adult?

Are you being charged as a juvenile?

Are you currently serving a sentence?

Are you on probation or parole (Including MSR or PRCS)? MSR is mandatory supervised release and PRCS is post release community supervision.

If you are on probation or parole, then what county is it in?

When does it end?

Do you have any juvenile record?

If yes, is it in Stanislaus County?

If no, where were your juvenile matters heard?

Clean Slate Confidential Program Questionnaire:

Describe why you want or need postconviction relief. How has your criminal history been a barrier to you? *

If you are making this request for employment purposes, please list licenses or jobs for which you might be qualified but for your past convictions. Describe any education or vocational training you may have received or job skills you may have and attach transcripts, certificates, or diplomas. *

Are you on at risk of experiencing harm, i.e., losing your job, housing, benefits, immigration status, custody of your children, etc., due to your criminal record? Please explain. *

Have you done or would you be willing to do volunteer work in the community? Where? If possible, please attach proof of completion of hours of community service completed subsequent to the date of your conviction: *

Do you still owe fines and fees associated with your case(s)? *

If the answer is "yes", are you financially able to pay any amount?

$ per week:

Do you understand that not everyone qualifies for help, that submitting this form does not guarantee that you will be assisted by us, and that it might take a few months to finish? *

Yes, I understand

I am not currently serving a sentence for an offense, on probation, parole, or post-supervision release for an offense, or charged with the commission of an offense. *

Yes

I understand that if, upon review of my criminal history report, it is determined that I am currently serving a sentence for an offense, on probation, parole, or post-supervision release for an offense, or charged with the commission of an offense, it will delay my application for relief and may temporarily or permanently bar eligibility for relief through the Clean Slate program. *

Yes

For any questions, about the application process, please contact the Stanislaus County Public Defender Clean Slate Program.