Erroneously Convicted Person Claim Form California Vic - PDF document

Page 1 of 2 Claimant’s Name: CDCR Inmate Number: Mailing Address: Section B. Attorney/Representative Information Section C. Conviction Information Date of Birth: Telephone Number: Erroneously Convicted Person Claim Form California Vic�m Compensa�on Board P.O. Box 350 Sacramento, CA 95812-0350 (888) 883-3593 | Fax: (916) 491-6441 Email: HearingO�cer@vic�ms.ca.gov Website: www.vic�ms.ca.gov State of California For O�cial Use Only City: Zip Code: State: Email Address (op�onal): Name of A�orney/Representa�ve: Mailing Address: Telephone Number: City: Zip Code: State: CALVCB-GC-EC01 (Rev. 09/2020) Signature of A�orney/Representa�ve: Signature Date: Felony or felonies for which claimant was convicted: Coun�es where the convic�on(s) occurred and the criminal court case number(s): Number of days incarcerated, both before and a�er convic�on: State prison(s) in which claimant’s sentence was served: Length of Sentence Imposed: Date of Convic�on: Date of Release from Imprisonment: Date of Discharge (if applicable): Date of Judgment of Acqui�al (if applicable): Date of Grant of Pardon (if applicable): Section A. Claimant Information Date of Finding of Factual Innocence: Page 2 of 2 Section D. Crime/Conviction Statement Provide facts showing: That the crime with which you were changed was either not commi�ed at all, or, if commi�ed, was not commi�ed by you; and That you did not plead guilty with the speci�c intent to protect another person from prosecu�on. (Please use addi�onal paper if necessary.) Section E. Pecuniary Injury Statement Provide facts showing that you would have been free from custody but for the erroneous convic�on. Please list every convic�on that was imposed at any �me during your con�nement. (Please use addi�onal paper if necessary.) Claimant’s Signature: Signature Date: I declare under the penalty of perjury, under the laws of the State of California, that the foregoing is true and correct: Section F. Declaration Statement Privacy Notice on Collection 1. CalVCB collects this informa�on based on California Government Code sec�ons 13952 et seq. and 13954, Penal Code All informa�on collected from this site is subject to, but not limited to, the Informa�on Prac�ces Act. See h�ps://vic�ms. ca.gov/media/pra.aspx . This informa�on is collected for the purpose of determining eligibility for compensa�on. CalVCB may disclose your personal informa�on to another requester, only if required to do so by law or in good faith that such ac�on is necessary to: a. Conform to the edicts of the law or comply with legal process served on CalVCB or the site; Protect and defend the rights or property of CalVCB; and, c. Act under exigent circumstances to protect the personal safety of users of CalVCB, or the public. Individuals are to provide only the informa�on requested. The informa�on provided is voluntary. 7. The consequences of not providing the requested informa�on could delay �ling the claim or the claim not being �led. 8. Any ques�ons regarding the informa�on collected, please write to the following address: PO Box 350, Sacramento, CA CustodianOfRecords @Vic�ms.ca.gov , call (888) 833-3593, or contact the CalVCB Privacy Coordinator at InfoSecurityAndPrivacy@Vic�ms.ca.gov .