Scribd
Upload
63 views

PC4900 Claim Form

This document is a claim form for erroneously convicted persons seeking compensation from the California Victim Compensation and Government Claims Board. The form requests information about the claimant such as name, contact details, conviction details including crime, county, dates of incarceration and release. It asks the claimant to provide statements describing how they did not commit the crime and did not intentionally contribute to their arrest or conviction. It also requests a statement about any financial losses sustained due to the erroneous conviction and imprisonment. The claimant must sign to declare under penalty of perjury that the information provided is true and correct.

Uploaded by

csandm
Copyright
© Attribution Non-Commercial (BY-NC)
Available Formats
Download as PDF, TXT or read online on Scribd
63 views

PC4900 Claim Form

This document is a claim form for erroneously convicted persons seeking compensation from the California Victim Compensation and Government Claims Board. The form requests information about the claimant such as name, contact details, conviction details including crime, county, dates of incarceration and release. It asks the claimant to provide statements describing how they did not commit the crime and did not intentionally contribute to their arrest or conviction. It also requests a statement about any financial losses sustained due to the erroneous conviction and imprisonment. The claimant must sign to declare under penalty of perjury that the information provided is true and correct.

Uploaded by

csandm
Copyright
© Attribution Non-Commercial (BY-NC)
Available Formats
Download as PDF, TXT or read online on Scribd
You are on page 1/ 2

Erroneously Convicted Person Claim Form

California Victim Compensation and Government Claims Board 400 R Street, Suite 500 Legal Division Sacramento, CA 95811 1-888-883-3593 www.vcgcb.ca.gov

State of California

For Office Use Only

Governed by Penal Code section 4900 et seq. and California Code of Regulations, Title 2, Division 2, Chapter 1, Article 5, sections 640 et seq.

Claimant Information
Claimants Name CDCR Inmate Number Date of Birth Telephone Number

(
Mailing Address City State Zip

Email Address (OPTIONAL)

Attorney / Representative Information


Name of Attorney/Representative Telephone Number

(
Mailing Address City

)
State Zip

Email Address (OPTIONAL)

Signature of Attorney/Representative

Date

Conviction Information
Felony(ies) for which claimant was convicted

County where conviction occurred

Number of days incarcerated after conviction

Date of Conviction

State prison(s) in which claimants sentence was served

Length of sentence imposed

Date of release from imprisonment

Date of discharge (If applicable)

Date of judgment of acquittal (If applicable)

Date of grant of pardon (If applicable)

Crime / Conviction Statement


Provide facts showing: A) That the crime with which you were charged was either not committed at all, or, if committed, was not committed by you; and B) That you did not intentionally contribute to your arrest or conviction. (Please use additional paper if necessary.)

Pecuniary Injury Statement


Provide facts showing the pecuniary injury (financial loss) sustained by you through your erroneous conviction and imprisonment. (Please use additional paper if necessary.)

I declare under the penalty of perjury, under the laws of the State of California, that the foregoing is true and correct: Claimants Signature Date
VCGCB GC ECO1 (Rev: 9/2011)

You might also like