Department of Corrections and Community Supervision Certificate of

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Department of Corrections and Community Supervision

Certificate of Relief from Disabilities - Certificate of Good Conduct

Application and Instructions

This is your application for a Certificate of Relief from Disabilities or for a Certificate of Good

Conduct. Please review this information carefully. Then, complete the application as best you can.

If you leave out information, it could take longer for the Department of Corrections and Community

Supervision (DOCCS) to make a decision about your application.

1) How do I know if I am eligible - Who can apply?

The information below can help you understand if you are eligible. For more information, you

can read Article 23 (Sections 700-706) of the New York State Correction Law.

I. Eligibility

A. CERTIFICATE OF RELIEF FROM DISABILITIES: You are eligible for this certificate if you

have been convicted of any number of misdemeanors and no more than one felony (two or

more felony convictions in the same court on the same day are counted as one felony for

deciding which certificate you are eligible for). The term “disability” refers to laws that

disqualify people from holding certain jobs or other rights because of their conviction.

B. CERTIFICATE OF GOOD CONDUCT: You are eligible for this certificate if you have been

convicted of two or more separate felonies or if you are seeking a job that is specifically

considered a “public office”. You must show that you have completed/achieved a certain

period of good conduct in the community. You must wait 5 years if the most serious felony

on your criminal record is an A or B felony, 3 years if the most serious felony on your criminal

record is a C, D or E felony, or 1 year if you only have misdemeanors on your criminal record.

The waiting period starts when you were last released from incarceration (prison or jail) to

community supervision, or were released from incarceration (prison or jail) by maximum

expiration of your sentence, or at the time of your last criminal conviction (which ever of

these events comes last). If you were convicted in another state or in federal court, the

waiting period will be determined by what the level of the conviction would be considered in

New York State.

DOCCS will only consider applications for Certificates of Good Conduct for public office if the

application lists a specific public office and includes information about laws that prevent the

individual from holding the office they want the Certificate for.

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2)

Where do I apply?

For Certificates of Relief From Disabilities, you should apply to the court that sentenced you

unless:

1. you were sentenced to a New York State (DOCCS) correctional facility, or

2. you were convicted in a federal court or a court in another state and you are now a

resident of New

York State.

Certificates in these cases are issued by the New York State

Department of Corrections and Community Supervision (DOCCS).

For Certificates Of Good Conduct, you must apply to the Department of Corrections and Community

Supervision.

Once you have decided which certificate you are eligible for, you should apply to the appropriate

agency/location.

 If you are applying to the DOCCS, fill out and mail the attached application to DOCCS at the

address on page 5.

 If you are applying to the sentencing court, you can get contact information from a telephone

directory or at www.nycourts.gov. Do not submit this application form to the sentencing court.

Courts use a different application form.

If you want information about restoring your firearms rights/privileges and were convicted

of a felony in a Federal Court, you must seek/request relief from the United States

Department of Justice, Office of the Pardon Attorney (www.justice.gov/pardon).

3) What do I need to provide to DOCCS to get my application considered?

 The Original Application Form – signed and notarized

 Copies of your Federal Income Tax Filings for the last two (2) years if you were required to

file a tax return.

 Copies of your Statement and Wages (Tax Form W-2) for the last two (2) years if you

earned wages.

 Copies of any miscellaneous income statements (Tax Form 1099) for the last two (2) years if

you received one.

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If you received public assistance, unemployment insurance, or Social Security benefits for any or all

of this two year period, you must include a printout from the agency that provided you with these

benefits/support, showing all the benefits that you received. If you had no reportable income for any

or all of this two year period (including any other benefits not listed above), you must provide

/submit a notarized document explaining how you supported yourself.

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4) What can I expect after my application has been submitted to DOCCS for review?

Once we receive your application, DOCCS will assign a field Parole Officer for an investigation.

The Officer will review:

1. Employment history and how you have supported yourself.

2. Proof that you have paid income taxes for the last two years.

3. Proof that you have paid any fines or restitution set by the courts.

After DOCCS has received all necessary documents and records from you, the field Parole Officer

assigned to you will contact you to arrange an interview at your home/residence to answer any

remaining questions and confirm your current circumstances and living situation. The New York

State Department of Corrections and Community Supervision will then examine your application to

decide whether to grant you a certificate. Under the law, DOCCS may choose to remove one, more

than one, or all allowable disabilities (restrictions created by law because of your conviction history).

Note that, under the law, individuals with certain conviction histories may be ineligible to have their

firearm rights restored.

5) How long will the process take?

This will vary depending on the complexity of your case. The process will involve a complete review

of the information you provide. Processing times depend on how complete the information you

provide to DOCCS is. The assigned Parole Officer will review and check all of the information you

provide. The process will be completed more quickly if you provide complete and accurate

information to the best of your ability and are available to the Parole Officer when he or she

contacts you.

The Parole Officer will want to see what you have been doing since your last conviction or release,

including information about:

 Going to school – such as a transcript or a letter from a teacher or school administrator;

 Job Training – such as a letter from a program supervisor or administrator;

 Employment – such as letters from supervisors or other people who worked with you;

 Counseling or social service program – such as a letter from a counselor, therapist or

doctor;

 Letters from Parole or Probation Officers;

 Letters from clergy;

 Letters from volunteer work

You do NOT need all of these items, only those that apply to you. For more examples, visit:

http://lac.org/wp-content/uploads/2014/12/How_to_Gather_Evidence_of_Rehabilitation_2013.pdf

Please note that the process will be delayed if you move any time after you submit your application. It

is therefore very important for you to let the Certificate Review Unit know if you move/relocate or

change your phone number after you submit your application.

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6) Who should I contact if I have questions or need help?

You can call DOCCS’s Certificate Review Unit at (518) 485-8953.

You can also contact the following organizations who are familiar with the process and have

experience assisting applicants

Anywhere in New York State (including New York City):

 Legal Action Center - (212) 243-1313

New York City:

 Community Service Society – (212) 614-5441)

 Neighborhood Defenders of Harlem (northern Manhattan residents; 96

th

street and above) –

212-876-5500

 Youth Represent – (212) 553-6421 or by email at info@youthrepresent.org (if you are under

the age of 24);

 Bronx Defenders – (718) 838-7878 or walk-in Monday to Friday from 9 AM to 5 PM at their

Client Reception space at 360 East 161st Street; (if you live in the Bronx)

Upstate New York

 Legal Assistance of Western New York (LAWNY) – LAWNY has 6 offices serving 14 counties

in western New York: Allegany, Cattaraugus, Chautauqua, Chemung, Livingston, Monroe,

Ontario, Schuyler, Seneca, Steuben, Tioga, Tompkins, Wayne and Yates Counties.

o Bath – (607) 776-4126,

o Elmira – (607) 734-1647,

o Geneva (315) 781-1465,

o Ithaca – (607) 273-3667,

o Jamestown - (716) 664-4535,

o Rochester - (585) 325-2520.

 Legal Aid Bureau of Buffalo - (716) 855-1553 (if you live in Erie County)

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7) Where should I send my completed application?

To apply to DOCCS, please complete the attached application form and return the original copy with

all

signatures notarized,

to this address:

STATE OF NEW YORK

DEPARTMENT OF CORRECTIONS AND COMMUNITY SUPERVISION

ATTN: CERTIFICATE REVIEW UNIT

The Harriman State Campus – Building 2

1220 Washington Avenue

Albany, NY 12226-2050

(518) 485-8953

To find out how to apply to the court that sentenced you, you can find the contact information for the

court in a phone directory or by visiting the web at www.nycourts.gov.

If you want to restore your firearms rights/privileges and were convicted of a felony in a

Federal Court, you must seek/request relief from the United States Department of Justice,

Office of the Pardon Attorney (www.justice.gov/pardon).

IMPORTANT INFORMATION (Detach and retain for your records)

If you are granted a Certificate, the Certificate will remove disabilities (such as license

disqualifications) caused by your conviction but it will not remove, seal, erase or expunge the

underlying conviction. You will still have a conviction and will have to tell employers and

licensing agencies about the conviction if they ask.

A Certificate also does not limit the right of a prospective employer or licensing agency from

using their lawful discretion to refuse you employment, or to refuse to grant or renew any

license, permit, or privilege.

A Certificate is not needed to restore your right to register for or vote in an election. Those

rights are completely restored when you reach the maximum expiration date of your sentence

or the termination of your sentence (Executive Law §259-j or Correction Law §205).

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C E R T I F I C A T E A P P L I C A T I O N

PURPOSE FOR REQUESTING CERTIFICATE:

Please provide your reason(s) or purpose for requesting a certificate:

Only check the reason(s) of primary interest to you:

Secure employment and/or improve employment opportunities

School bus driver

Notary Public

Long guns

Handguns

Other (Please specify) _________________________________

For Long guns and/or Handguns please specify reason(s) for request (i.e., Hunting, Target, Armed

Security Work, etc):

APPLICANT IDENTIFYING INFORMATION:

Name: ________________________________________________________________________

(Last) (First) (Middle) (Suffix)

Date of Birth: ________________________ Gender: Male Female

Race: Ethnicity:

White Hispanic

Black/African American Non-Hispanic

American Indian

Asian

Other

Social Security Number: _______ - ______ - _______

Height: ___________ Weight: ___________ Eye Color: __________ Hair Color: __________

Have you ever been known by any other legal name or alias other than the name on this application?

If yes, indicate below and state reason(s) for change of name:

Name Reason for Legal Name Change

______________________________________ ___________________________________

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RESIDENCE HISTORY:

Present Address: ______________________________________________________________

(Street) (City) (State) (Zip Code)

______________________________________________________________

(Apt. No.) (Home Phone/Cell Phone) (County)

For your current address, list everyone who lives with you below:

Name Age Relationship

____________________________________ _________ ______________________________

To the best of your knowledge, list ALL previous residences (including your present residence, as

well as any time that you were homeless or lived in medical or other housing for the past two (2)

years:

Address (Include City and State) From/To

________________________________________________________ ___________________

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EMPLOYMENT HISTORY:

To the best of your knowledge, list your occupations/jobs and employers for the past two (2) years.

Start with your present employer and work back. For each period of unemployment, provide dates:

Dates (mo. & yr.) Occupation Name & Address Full Immediate Weekly

From To Job/Position of employer or P/T Supervisor Salary

_____ Present ________________ _________________________ __ ______________ _______

_____ _____ ________________ _________________________ __ ______________ _______

DOCCS will only contact an employer as part of the investigation process if after your

interview there is information that requires additional verification and DOCCS will not discuss

your conviction with any employer.

CITIZENSHIP:

Are you a citizen of the Unites States? (check one)

Yes, by birth Yes, by Naturalization, Certificate Number __________________

If not a citizen, provide _____________________________ ____________________________

Alien registration Number Country

MILITARY SERVICE HISTORY:

If you ever served in the Unites States military, please provide:

Branch of Service: _________________________ Date of entry into Active Duty: ___________

Date of Discharge: _________________________ Honorable Discharge: Yes No

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LEGAL HISTORY:

If known: NYSID # ___________________ FBI # ________________ Prison #______________

Record of out-of-state or federal convictions (DOCCS has access to your New York conviction

information):

To the best of your knowledge, please list all out-of-state or federal convictions and adjudications.

Conviction Court of Conviction Conviction Charge Sentence

Date (Include State, County and/or City) (Do not use codes)

________ ___________________________ ________________________ ________________

If you have been on out-of-state or federal probation/parole, please check below:

Probation Parole

From To To the best of your knowledge Parole/Probation Officer’s name and address where you reported

_______ _______ ______________________________________________________________

If you were committed to local jail or other adult facility in the past two (2) years, please provide the

information below to the best of your knowledge:

Date of Conviction Conviction Charge Name of Facility/Institution and Location Date of Release

_____________ ______________ ____________________________________ ____________

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If you previously applied for a Certificate of Relief from Disabilities, please provide:

Place: _______________________________ Date: _____________ Was it granted: __________

If you previously applied for a Certificate of Good Conduct, please provide:

Place: _______________________________ Date: _____________ Was it granted: __________

Have you ever had an Order Of Protection (OOP) issued against you?

If yes, please provide the information below to the best of your knowledge.

Date of OOP Court of OOP Person(s) Protected by OOP Date of OOP

Issuance Issuance Expiration

_________ ____________________ ____________________________________ ________

SOCIAL STATUS:

Marital Status: Single Married Separated Divorced Widow(er) Annulled

How many times have you been married? ______

For each marriage, please give the following information:

Name Used Wife’s Maiden Name or Date Married/

(If different from name used on this application) Husband’s Full Name Divorced

________________________________ _____________________________ ______________

If during the past two (2) years you lived with a roommate(s) or live-in partner(s) to whom you were

not legally married, please provide name(s) and current address below.

Use reverse side of paper if additional space is required.

Name Address

______________________________ ______________________________________________

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LICENSE INFORMATION:

Licenses you hold (Motor Vehicle, Trade, Professional or Pistol Permit):

Please use reverse side of paper if additional space is required.

Type of License Licensing Agency License Number Date Issued Expires

_______________ _______________ ____________________ ____________ ___________

REFERENCES:

Please provide the complete names and mailing addresses of two (2) people who we can contact to

provide character references on your behalf:

Name Address Phone

_________________________ ____________________________________ ______________

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I agree to allow an investigation to be made to determine my fitness for a certificate pursuant to

Article 23 of the NYS Correction Law. I hereby certify that I have fully and truthfully answered all of

the above questions.

Applicant’s Signature: _____________________________________ Date: __________________

MUST BE SIGNED BY A NOTARY PUBLIC

State of New York

County of _____________________

______________________________ being duly sworn, deposed and says that he/she is the

applicant named within the application: the he/she has read the foregoing application and knows the

contents thereof; that the same is true to his/her own knowledge, except as to the matters therein

stated to be alleged on information and belief, and that as to those matters he/she believes it to be

true.

___________________________________________

Notary Public

Authorization for release of information

I, _____________________________________, have applied to the New York State Department of

Corrections and Community Supervision for a Certificate of Relief from Disabilities/Good Conduct. To

facilitate the investigation of my application, I hereby authorize any individual, private business

concern, state or federal agency to release to any authorized representative of the Department of

Corrections and Community Supervision any information such person, private business concern.

State or federal agency may have in its possession concerning me or my activities.

Applicant’s Signature: _____________________________________ Date: __________________

___________________________________________

Notary Public