Executive Clemency Application Form – Fill Out and Use This PDF

My reason(s) for applying for a commutation of my sentence (time cut):

1.I wish to correct an in-justice which may have occurred during the trial, I have attached letters or other documentation that will support this claim. If you wish to attach an explanation or statement to this application, it will be considered as a part of the application. Discuss results of appeals or Rule 37 or other post conviction proceedings in an attached statement.

2. I have a life-threatening a medical condition which does not qua i y for Act 290, I have

attached a statement explaining my condition. Your medical statement will be validated by ADC Medical Services before being sent to the Post Prison Transfer Board.

3.I want to adjust what may be considered an excessive sentence.

4.My institutional adjustment has been exemplary and the ends of -justice have been achieved,

NOTE:

A.All supporting documentation must be available when the Board considers your application.

B.The Board will ordinarily not consider your application if your case is currently being appealed or if a Rule 37 petition or other petition of post-conviction relief is pending.

C.If your application is based on your belief that your sentence is excessive or that your institutional adjustment has been exemplary and the ends of justice have been achieved, the application will ordinarily be denied if you have not served the portion of your sentence indicated by the following table:

If you believe that this table should not apply in your case, you should attach a statement of your reasons to this application.

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1Give the full name under which you were convicted and any alias names you have used:

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2.List all crime(s) for which you have been convicted, the county of conviction, date of conviction, docket number, and sentence. (Sentence may include fines, probation*, suspended sentence or time incarcerated in then Arkansas Department of Correction or the Department of Community Punishment.)

NOTE: Please attach a separate sheet if necessary to include all offenses.

*Please include a copy of any orders of probation or suspended sentence you may have received.

If yes, list the names of your accomplices and what, if any, sentences they received.

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6.Concerning the facts of the crime, briefly explain what happened.

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7.What is your reason for requesting executive clemency at this time?

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CRIMINAL HISTORY

List all juvenile, misdemeanor, DWI traffic violations, etc, or crimes committed outside the state of Arkansas. Do not include convictions fisted in response to question 2 above.

If married, what is your spouse's full name?_________________________________

When and where were you married?______________________________________

2.For any previous marriages, List the following information:

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DUCATIONAL BACKGROUND:

List the following information about all schools you have attended, including any vocational-technical training:

Name & Address of SchoolDate of Attendance Highest Grade Completed/Degree

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EMPLOYMENT BACKGROUND:

IPlease provide the following information about your current job:

Name of employer:____________________________________________________________

Employer's address:___________________________________________________________

When were you hired:_________________________________________________________

Give a brief description of your job responsibilities:__________________________________

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2.If you are currently unemployed, but on disability, please list how you became disabled (work-related injury, etc.)________________________________________________________

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3.For previous jobs you have held, list the following information:

5.Have you ever received treatment for alcohol or drug problems (example: Alcoholics

Anonymous)? Yes No

If yes, please provide a brief explanation:

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By signing this application, I hereby swear that the information Provided is one and accurate to the best of my knowledge.

Applicant's Signature

Date of application

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