Streamlined Application for Restoration of Citizenship Rights
(Right to Vote and Hold Public Of?ce)

READ CAREFULLY. IF YOU DO NOT COMPLETE THE APPLICATION IN FULL,
IT WILL BE RETURNED TO YOU WITHOUT PROCESSING.

General Informatiog: A restoration of citizenship restores the right of a person to vote and hold public
of?ce. This is not an application for pardon. commutation or a special restoration of citizenship rights
(?rearms 1. If you would like to apply for pardon, commutation or a special restoration of citizenship
rights (firearms), you must submit a different application, which can be found on the Governor?s website
at or by contacting the Governor?s Of?ce at 5i5/281-5211.

Who may apply: An individual convicted in Iowa State Court, Federal Court, and a court outside of
Iowa may apply to have their right to vote and hold public of?ce restored.

How to obtain your restoration of Citizenship Rights:
(1) Complete the application attached.
(2) Sign the release of information attached to the application.
(3) Submit documentation of your court costs, restitution, and ?nes.

Completed payment: If you have completed your payment of court costs, restitution, and ?nes you
must submit documentation verifying your payment. You may call the courthouse of your conviction
for veri?cation or call your local Community Based Corrections Of?ce for assistance. To find
information regarding your courthouse or your local Community Based Corrections Of?ce, you may
call 515/725-5701.

Still working on payment: If you are current on your payment of court costs, restitution, and ?nes and
continue to pay these costs in good faith, you must submit documentation of your payments along with.
an explanation of your payments and why they are not completed. You may call. the courthouse of
your conviction for veri?cation or call your local Community Based Corrections Office for assistance.
To ?nd information regarding your courthouse or your local Community Based Corrections Of?ce,
you may call 515/725?5701.

(4) You must submit an Iowa Criminal History Record. To request an Iowa Criminal History Record,
contact: Iowa Division of Criminal Investigation
215 East 7th Street
Des Moines, Iowa 50319
Phone: 515/725-6066

m: (1) Your completed application, (2) Release, (3) Documentation verifying the payment of your
court costs, fines and restitution; and (4) Iowa Criminal History Record, and send it to:

Legal Counsel

Governor?s Of?ce

State Capitol Building

Des Moines, Iowa 50319

Questions: You make call. 515/281-521l or visit the ?Frequently Asked Questions? at:


 of 
(Make sure all items are enclosed in your application)

Step 1 Complete, Sign, and date application

- Make sure you answer all of the questions.
- You may call Iowa Department of Corrections at 5 I 5/725-5 701 to obtain the phone number
for your local Community Based Corrections Of?ce to help you fill out the application.

Step 2 Sign the Release attached to the application

Step 3 Enclose Proof of payment of court costs, ?nes, and restitution
You may call Iowa Department of Corrections at 515/725-5701 to ?nd where you can locate
this information

Step 4 Enclose a Current Iowa Criminal History Record

- You may call Iowa Department of Criminal Investigations at 51 5/725-6066 to obtain your
Iowa Criminal History.

El Step 5 Place the information from Steps 1, 2, 3, and 4 into an

envelope and mail it to:
Legal Counsel
Governor?s Of?ce
State Capitol Building
Des Moines, Iowa 50319

Step 6 Make a copy of the application and material submitted for

your records.

Failure to disclose true and accurate information may affect your application.
There is no application fee for clemency.

TERRY E.

GOVERNOR

OFFICE OF THE GOVERNOR

BRANSTAD

Application for Restoration of Citizenship Rights - Right to Vote and Hold Public Of?ce
(Application current as of April 17, 2014)

TO: Governor Terry E. Branstad, I hereby make application for Restoration of Citizenship Rights (Right to Vote and Hold Public Of?ceKIM REYNOLDS
LT. GOVERNOR

 

 

 

 

 

 

 

Name: Other Names (ie: maiden)
Address:
Street City State Zip Code County

. Home Phone: Work Phone: Cell Phone: 
. Date of Birth: Place of Birth: Sex: Male/Female
. Social Security Number: US Citizen (circle one) Yes or No

Crime/Offense: Classi?cation of Crime (ie: Class felony):
. Date of Crime (Month/Day/Y ear):
. Date of Conviction (Month/Day/Y ear):
. County and State of Conviction:

 

10. Court in which convicted in:

 

11. Sentence Received:

 

12. Place and Dates of Time Served:

13.

14.

15.

16.
17.
18.
19.
20.

21.
22.
23.

 

Beginning and Ending Date of Parole:

 

 

 

 

 

 

 

 

 

 

or Probation: or both:
Name and Current Address of Parole or Probation Of?cer:
Name and Current Address of Prosecuting Attorney:
Name and Current Address of Defense Attorney:
Name and Current Address of Judge who heard Case:
Were you ordered to pay court costs? Yes No Amount
If ordered, amount you have paid:
Was any restitution ordered? Yes No
Amount ordered: Amount you paid:

 

 

Attorney?s fees: Amount you paid:

 

 

Court costs owed: Amount you paid:

 

 

Your address at time charged and convicted:

 

 

STATE CAPITOL DES MOINES, IOWA 50319 515.281.5211

FAX 515.725.3527 

24. Have you ever been arrested charged or convicted of an offense at any other time? (include deferred
judgments. If you were a juvenile at the time of your conviction, what was the disposition of the case? Were

the records sealed?)

 

(Please circle): Yes No

25. If the answer to Question #24 is yes, provide the following information for each offense. {Attach additional Sheets if
needed.)

9?



26. List any alimony or child support payments you were ordered to make:

a.
b. Please list the amount of alimony or child support you are presently paying:

Crime or offense:

 

Date of offense:

 

Sentence received:

 

Terms of sentence:

 

County and state where convicted or charged:

 

Place and dates of incarceration and:

 

Dates of probation or parole:

 

Amount of restitution, court costs and attorney?s fees ordered and amount paid:

 

Restitution ordered: Amount paid:

(2) Court Costs ordered:

 

Amount paid:

 

 

(3) Attorney?s fees ordered: Amount paid:

 

 

 

Have you paid all of the alimony and child support you have been ordered to pay? Yes/ No/ Not Applicable

 

27. Have you made a previous application for executive clemency (citizenship, ?rearms or pardon)?

If yes, when and in what state?

 

28. Did you ?le federal and state income tax returns for the following yearsLast Year? Yes

d. Three Years Ago? Yes

This year?

Two Years Ago? No No

If you did not ?le either the federal or state tax. return or both, please explain which returns(s) you did
not file and why.

 

 

29. Please state why you believe that you have demonstrated good citizenship such that your citizenship
rights (right to vote and hold. public of?ce) might be restored by the Governor. (You may additional sheets of
paper if necessary.)

 

 

 

 

I certify, under the penalty of perjury, that my application is true and complete.

 

 

Signature of Appiicant Print Name of Applicant

RELEASE

YOU MUST SIGN AND DATE THIS RELEASE FORM
OR YOUR APPLICATION WILL NOT BE PROCESSED

I, the undersigned applicant for executive clemency to the
Governor of the State of Iowa, do hereby authorize any and all persons, firms or corporations, to release
any and all information or documents they may now have or hereinafter receive concerning me.

 

I authorize the release of said information to the Governor of the State of Iowa, his designee or agent. In
granting this release, it is my understanding that the information or documents obtained will be used for
the sole consideration of my application for executive clemency.

I further forever hold blameless those persons, firms, corporations and the Governor?s Of?ce, who by
virtue of this consent may release information as requested.

A photocopy of this release form will be valid as an original, even though said photocopy does not
contain an original writing of my signature.

I have read fully and understand the contents of this application and the authorization for release of
personal information.

 

Signature of Applicant

 

Print Name of Applicant

Date of Application:

 

STATE OF IOWA
Criminal History Record Check
Request Form
DCI Account Number: _________________
(if applicable)

To:

Iowa Division of Criminal Investigation
Support Operations Bureau, 1st Floor
215 E. 7th Street
Des Moines, Iowa 50319
(515) 725-6066
(515) 725-6080 Fax

From:

Phone:
Fax:

I am requesting an Iowa Criminal History Record Check on:

Last Name (mandatory)

First Name (mandatory)

Middle Name (recommended)

Date of Birth (mandatory)

Gender (mandatory)

Social Security Number (recommended)

Male

Female

Waiver Information: Without a signed waiver from the subject of the request, a complete criminal history record may not
be releasable, per Code of Iowa, Chapter 692.2. For complete criminal history record information, as allowed by law, always
obtain a waiver signature from the subject of the request.

Waiver Release: I hereby give permission for the above requesting official to conduct an Iowa criminal history record check with the Division of Criminal
Investigation (DCI). Any criminal history data concerning me that is maintained by the DCI may be released as allowed by law.

Waiver Signature: ___________________________________________________________________________

Iowa Criminal History Record Check Results
As of ___________________, a search of the provided name and date of birth revealed:
No Iowa Criminal History Record found with DCI
Iowa Criminal History Record attached, DCI #______________
DCI initials______________
DCI-77 (08/25/10)

(DCI use only)

 Waiver Information:
Iowa law does not require a waiver. However, without a signed waiver from the subject of the
request any arrest over 18 months old, without a final disposition, cannot be released to a non-law
enforcement agency.
Deferred judgments where DCI has received notice of successful completion of probation also cannot
be released to non-law enforcement agencies without a signed waiver from the subject of the request.
If the “No Iowa Criminal History Record found with DCI” box is checked, it could mean that the
information on file is not releasable per Iowa law without a waiver.
General Information:
The information requested is based on name and exact date of birth only. Without fingerprints, a
positive identification cannot be assured. If a person disputes the accuracy of information maintained
by the Department, they may challenge the information by writing to the address on the front of this
form or personally appearing at DCI headquarters during normal business hours.
The records maintained by the Iowa Department of Public Safety are based upon reports from other
criminal justice agencies and therefore, the Department cannot guarantee the completeness of the
information provided.
The criminal history record check is of the Iowa Central Repository (DCI) only. The DCI files do not
include other states’ records, FBI records, or subjects convicted in federal court within Iowa.
In Iowa, a deferred judgment is not considered a conviction once the defendant has been discharged
after successfully completing probation. However, it should be noted that a deferred judgment may
still be considered as an offense when considering charges for certain specified multiple offense
crimes, i.e. second offense OWI. If a disposition reflects that a deferred judgment was given, you
may want to inquire of the individual his or her current status.
A deferred sentence is a conviction. The judge simply withholds implementing a sentence for a
certain probationary period. If probation is successful, the sentence is not carried out.
Any questions in reference to Iowa criminal history records can be answered by writing to the address
on the front of this form or calling (515) 725-6066 between 8:00 a.m. and 4:30 p.m., Monday Friday.
REMINDER - (1) Send in a separate Request Form for each last name, (2) a fee is required for each
last name submitted, (3) a completed Billing Form must be submitted with all request(s).
Iowa law requires employers to pay the fee for potential employees’ record checks.

Request Form
Page 2

 STATE OF IOWA
Criminal History Record Check
Billing Form
Date:
To:

DCI Account Number:
Iowa Division of Criminal Investigation
Support Operations Bureau, 1st Floor
215 E. 7th Street
Des Moines, Iowa 50319
(515) 725-6066
(515) 725-6080 Fax

From:

Phone:
Fax:

A completed Billing Form is required when submitting record check requests to the DCI.
Each last name submitted requires a separate Request Form with payment for each.
Only one Billing Form is needed when submitting several requests at the same time.
Payment must be included unless a pre-paid account is established.
All pre-paid accounts must submit an Account Number.
Please check either Mail Back or Fax Back results; we will not do both.
Mail Back Results

Fee per request

Fax Back Results

$15.00

Number of requests submitted: x

*If neither box above is checked, results
will be mailed back to the address provided.

Amount Due: $

METHOD OF PAYMENT
(Checks should be made payable to the Iowa Division of Criminal Investigation)
Check

#__________

Cash

Money Order

Pre-paid Account

MasterCard/Visa/Discover:

Interagency

Expiration Date:

Cardholder’s Name:
On the lines provided below, please write the last name(s) of the person(s) you are submitting the record check
on. This is important for tracking purposes.
1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

DCI 76 (08/25/10)

  

This is a form created by the ACLU of Iowa to help applican ts for restoration of voting
rights more easily answer the question posed by the Governor's Of?ce, as part of the
application process, on why they are not current on their payments.

Date: (Month/ Day/ Year)

Re: EXPLANATION OF PAYMENTS

To Whom It May Concern:

As the attached documentation shows, I am current on my payments for court costs,
restitution, and ?nes. However, I have not completed (paid in full) my court costs,

restitution, and ?nes.

I am currently paying: each (week, month, year)
(State the amount of money, usually set up in payments, that you are

paying-)
Check one or both of the following:

The reason my payments are not completed (paid in full) is:

I cannot ?nancially afford to pay a lump sum.

I: Other. Please explain:

 

 

 

Name: (Please print)

 

Name: (Your signature)

 

When completed, this form should be sent, along with your other application
materials, to:

Legal Counsel
Governor's Of?ce
State Capitol Building
Des Moines, IA 50319