Mississippi Clemency Form – Fill Out and Use This PDF

STATE OF MISSISSIPPI

OFFICE OF THE GOVERNOR

APPLICATION FOR CLEMENCY

The applicant MUST complete the application for clemency (use extra paper if necessary.)

CONSIDERATION OF THIS APPLICATION DOES NOT NECESSARILY RESULT IN THE CLEMENCY REQUEST BEING GRANTED.

___ Pardon	___ Commutation of Sentence		___ Restoration of Civil Rights
1. NAME:_________________________________________________________________________________
	Last	First	Middle
2. SOCIAL SECURITY #		3. DATE OF BIRTH_________________________

4.DEPARTMENT OF CORRECTIONS NUMBER:_______________________________________________

5.ADDRESS:______________________________________________________________________________

StreetCity

___________________________________________ 6. PHONE NUMBER:____________________

State	Zip
7. MARITAL STATUS: ____________________		8. SPOUSE'S NAME:___________________________
9. SPOUSE'S ADDRESS: ____________________________________________________________________
	Street	City	State	Zip

10. NAMES AND AGES OF DEPENDENT

CHILDREN:___________________________________________

__________________________________________________________________________________________

11.CRIMINAL CHARGES OR CONVICTIONS (Include ALL past and pending charges regardless of conviction. Include felony(s) and/or misdemeanor(s), excluding traffic violations - use extra paper if necessary):

a)__________________________________________________________________________________

Charge	Conviction Received
____________________________	___________________________________
Date Convicted	County of Court
____________________________	___________________________________
Judge	Prosecutor
____________________________	___________________________________
Defense Attorney	Sentence
____________________________	___________________________________
Period of Incarceration	Place Incarcerated

b)__________________________________________________________________________________

Charge	Conviction Received
____________________________	___________________________________
Date Convicted	County of Court
____________________________	___________________________________
Judge	Prosecutor
____________________________	___________________________________
Defense Attorney	Sentence
____________________________	___________________________________
Period of Incarceration	Place Incarcerated

12. If ever incarcerated, state every instance the applicant received disciplinary action (be specific):

3)__________________________________________________________________________________

17.Has the Applicant ever received clemency:____________________

18.Has the Applicant ever been on parole? ____________________ If yes, has the Applicant ever been found in violation of any terms or conditions of the parole?____________________ If yes, explain on extra paper.

19.Has the Applicant ever been on probation? ___________________ If yes, state the name(s) and address(es) of the Applicant's probation officer(s):

__________________________________________________________________________________________

__________________________________________________________________________________________

20.Has the Applicant ever been found in violation of any terms or conditions of the probation? _______________ If yes, explain on a separate sheet of paper.

21.In a separate letter, which must accompany this application, state the extenuating circumstances supporting the basis for the clemency request.

22.Letters of recommendation in support of the request for clemency must accompany this application. Letters may be submitted from all sources, including but not limited to the following: neighbors, employers, co-workers, pastors, church members, elected officials, judges, prosecutors, family members, etc....

23.Name, address and phone number of person(s) to contact if we need to contact you on an emergency basis.

I SWEAR OR AFFIRM THAT THE INFORMATION REPORTED IN THIS APPLICATION FOR CLEMENCY AND ANY ACCOMPANYING MATERIAL IS COMPLETE AND ACCURATE.

_________________________	_____________________________________
Date	Signature

COMPLETION OF THE APPLICATION, WHICH MUST BE IN FULL, MEANS ONLY THAT THE APPLICANT MAY BE CONSIDERED FOR CLEMENCY, NOT THAT ONE WILL BE GRANTED.

Promptly notify us concerning any change of address or change in telephone listing.

Return completed Application for Clemency with letter which states the extenuating circumstances supporting the basis for the clemency request to:

Office of the Governor

Attn: Legal Division

PO Box 139

Jackson, MS 39205-0139