With knowledge of the penalties for false statements to Federal Agencies, as provided by 18 U.S.C. § 1001, and with knowledge that this statement is submitted by me to affect action by the U.S. Department of Justice, I certify that:
The applicant was either a U.S. citizen or lawfully present in the United States at the time of the offense; and The applicant was a U.S. citizen or lawful permanent resident on December 22, 2023; and The statements and accompanying documents included in this form are true and complete to the best of my knowledge, information, and belief; and I acknowledge that any certificate issued in reliance on the above information will be voided, if the information is subsequently determined to be false; and The applicant has read and understands the Privacy Act Statement: The Office of the Pardon Attorney has authority to collect this information under the U.S. Constitution, Article II, Section 2 (the pardon clause); Orders of the Attorney General Nos. 1798-93, 58 Fed. Reg. 53658 and 53659 (1993), 2317-2000, 65 Fed. Reg. 48381 (2000), and 2323-2000, 65 Fed. Reg. 58223 and 58224 (2000), codified in 28 C.F.R. §§ 1.1 et seq. (the rules governing petitions for executive clemency); and Order of the Attorney General No. 1012-83, 48 Fed. Reg. 22290 (1983), as codified in 28 C.F.R. §§ 0.35 and 0.36 (the authority of the Office of the Pardon Attorney). The principal purpose for collecting this information is to enable the Office of the Pardon Attorney to issue an individual certificate of pardon to you. The routine uses which may be made of this information include provision of data to the President and his staff, other governmental entities, and the public. The full list of routine uses for this correspondence can be found in the System of Records Notice titled, "Privacy Act of 1974; System of Records," published in Federal Register, September 15, 2011, Vol. 76, No. 179, at pages 57078 through 57080; as amended by "Privacy Act of 1974; System of Records," published in the Federal Register, May 25, 2017, Vol. 82, No. 100, at page 24161, and at the U.S. Department of Justice, Office of Privacy and Civil Liberties' website . You consent to allowing the Office of the Pardon Attorney to obtain information regarding your citizenship and/or immigration status from the courts, from other government agencies, from other components within the Department of Justice, and from the Department of Homeland Security, U.S. Citizenship and Immigration Services (DHS-USCIS), Systematic Alien Verification for Entitlements (SAVE) program. The information received from these sources will be used for the sole purposes of determining an applicant's qualification for a Certificate of Pardon under the December 22 proclamation and for record-keeping of those determinations. Further, please be aware that if the Office of the Pardon Attorney is unable to verify your citizenship or immigration status based on the information provided below, we may contact you to obtain additional verification information. Learn more about the DHS-USCIS's SAVE program and its ordinary uses .
Your disclosure of information to the Office of the Pardon Attorney on this form is voluntary. If you do not complete all or some of the information fields in this form, however, the Office of the Pardon Attorney may not be able to effectively respond. Information regarding gender, race, or ethnicity is not required and will not affect the processing of the application.