Legal Pardon ROI Form

LEGAL PARDON ROI FORM

This Release of Information (this "Authorization") is entered into by and between Applicant Name: , Date of Birth: , Last 4 of SSN: (the "Applicant"), and Authorized Recipient/Representative: , Address: (the "Recipient"). This Authorization permits disclosure, copying and release of records as set forth below for the purpose of evaluating, preparing, and filing a petition for executive clemency, pardon, or other post-conviction relief on behalf of the Applicant.

RECITALS

WHEREAS, the Applicant seeks to obtain records necessary to prepare and present a petition for pardon or other executive clemency; and

WHEREAS, the Applicant authorizes designated agencies and custodians of records to disclose and transmit relevant records to the Recipient for use in connection with the Applicant's request for clemency; and

WHEREAS, the parties desire written evidence of the scope of authorization and the terms under which records may be released and used.

NOW, THEREFORE, in consideration of the mutual promises contained herein and other good and valuable consideration, the sufficiency of which is acknowledged, the parties agree as follows:

1. AUTHORIZATION

The Applicant hereby authorizes any and all courts, law enforcement agencies, prosecuting authorities, correctional institutions, probation and parole offices, medical providers to the extent records relate to incarceration or court-ordered treatment, educational institutions, employers of record, and other custodians of records (collectively, "Custodians") to disclose, release and transmit to the Recipient and Recipient's agents and attorneys all records and information pertaining to the Applicant as described in Section 2 below. This authorization extends to both completed and pending matters and includes information protected by privacy laws to the extent permitted by law and this Authorization.

2. SCOPE OF RECORDS TO BE RELEASED

The scope of records and information authorized for release includes, but is not limited to, the following categories. Indicate authorized categories by checking the applicable boxes:

Criminal conviction records and docket entries (including judgments and sentencing transcripts) Arrest reports and incident reports Court files, charging documents, plea agreements, and clerk's records Probation, parole, supervision files, violation records and certificates of completion Jail and prison records, institutional behavior reports, and release records Medical records related to incarceration, treatment or court-ordered evaluations Education and employment verifications, diplomas and transcripts Driver history and DMV records (if relevant) Other records (describe below)

3. AUTHORIZED CUSTODIANS

The Applicant authorizes disclosure by Custodians including, but not limited to, state and local courts, county clerks, state departments of corrections, county jails, municipal police departments, sheriff's offices, state police, probation and parole offices, and treatment providers. The Applicant specifically authorizes Custodians in the following jurisdictions and agencies to release records to the Recipient:

4. PURPOSE

The purpose of this Authorization is to permit the Recipient to obtain records to evaluate, prepare, and support a petition for pardon or other executive clemency or post-conviction relief on behalf of the Applicant. Records obtained pursuant to this Authorization may be used in legal filings, investigative reports, advocacy, and communications with executive clemency authorities.

5. DURATION AND REVOCATION

This Authorization shall be effective as of the date of signature below and shall remain in effect until: (a) the purpose described in Section 4 is fulfilled; (b) the Applicant provides written revocation to the Recipient; or (c) the following date: , whichever occurs first. Revocation shall not apply to records already released in reliance upon this Authorization prior to receipt of revocation.

6. METHOD OF DISCLOSURE

The Applicant authorizes Custodians to provide records by mail, facsimile, secure electronic transmission, or other customary means to the Recipient at the address or contact information provided below. The Applicant expressly authorizes release of photocopies and certified copies of records where available.

7. FEES

The Applicant authorizes payment of reasonable reproduction, retrieval, and certification fees assessed by Custodians. The Recipient may pay such fees on behalf of the Applicant and seek reimbursement. The Applicant is responsible for any fees required by law to obtain certified copies of records unless otherwise agreed in writing.

8. CONFIDENTIALITY; LIMITATIONS ON USE

Records obtained pursuant to this Authorization may contain sensitive information. The Recipient agrees to maintain confidentiality of such records consistent with applicable law and to use records solely for the authorized purpose set forth in Section 4. The Recipient shall not re-disclose records to third parties except as necessary to pursue the clemency petition or as required by law, and shall inform such third parties of the confidential nature of the information.

9. RELEASE AND INDEMNIFICATION

The Applicant releases Custodians and the Recipient from liability for disclosure of records made in good faith pursuant to this Authorization. The Applicant agrees to indemnify and hold harmless the Recipient from any claims or damages arising from the Applicant's failure to disclose material information or from reliance on records provided under this Authorization, except to the extent caused by the Recipient's gross negligence or willful misconduct.

10. REPRESENTATIONS AND WARRANTIES

The Applicant represents and warrants that the Applicant is the person identified herein or has proper authority to execute this Authorization on behalf of the person identified, that the information provided is true and accurate, and that this Authorization is given voluntarily. The Recipient represents that it will use records only for the stated purposes and will comply with applicable statutory restrictions on dissemination of records.

11. NOTICES

All notices required or permitted under this Authorization shall be in writing and delivered to the addresses set forth below or to such other address as a party may specify in writing.

12. AMENDMENT; WAIVER; COUNTERPARTS

This Authorization may be amended only by a written instrument signed by the Applicant and the Recipient. No waiver of any provision shall be effective unless in writing and signed by the party granting the waiver. This Authorization may be executed in counterparts, each of which shall be deemed an original and all of which together shall constitute one instrument.

13. GOVERNING LAW; SEVERABILITY; ENTIRE AGREEMENT

This Authorization shall be governed by and construed in accordance with the laws of the state in which the Applicant resides at the time of signature, without regard to conflicts of law principles. If any provision of this Authorization is held invalid or unenforceable, the remaining provisions shall remain in full force and effect. This Authorization constitutes the entire agreement between the parties with respect to the subject matter herein and supersedes all prior and contemporaneous agreements and understandings, written or oral.

14. CERTIFICATION

The Applicant certifies under penalty of perjury under the laws of the relevant jurisdiction that the information provided in this Authorization is true and correct to the best of the Applicant's knowledge and that the Applicant is the person identified herein or is authorized to execute this Authorization on behalf of such person.

15. ACKNOWLEDGMENT OF RIGHTS

The Applicant acknowledges that the Applicant has the right to inspect the records disclosed pursuant to this Authorization to the extent provided by law and that the Applicant may revoke this Authorization at any time by providing written notice to the Recipient, subject to the limitations set forth in Section 5.

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