A. Personal Information
Full Legal Name: *
Any Other Names/Aliases You Have Used:
Date Of Birth: *
Current Street Address:
City, State, Zip:
County
Phone Number:
E-Mail:
Do you have a TN Driver’s License or State ID?
B. Conviction & Sentence History
Conviction 1: * Offense/Crime:
State of Conviction (e.g.,TN, GA, Federal)
County & Court (e.g., Shelby County Circuit Court):
Case/Docket Number:
Date of Conviction:
Was your full sentence completed (including incarceration, probation, and parole)?
If yes, date of final discharge:
Name of last Probation/Parole Officer or Agency:
C. Financial Obligations
Do you owe any outstanding court-ordered restitution from your case(s)?
If yes, what is the approximate amount owed? $
Do you owe any outstanding court costs from your case(s)?
If yes, what is the approximate amount owed? $
Are you current on all child support payments?
D. Additional Information
Have you ever been pardoned or had your voting rights restored previously?
1. If yes, please explain:
2. Do you require any disability-related accommodations?
AUTHORIZATION FOR RELEASE OF RECORDS
To receive pro bono legal assistance in restoring your voting rights, we require your consent to access records relevant to your case. Please read the following authorization carefully before submitting.
AUTHORIZATION STATEMENT
By submitting this form, I, the undersigned, authorize [Organization Name] and its attorneys, employees, and authorized agents to request, inspect, and receive copies of any records pertaining to me solely for the purpose of evaluating my eligibility for and pursuing the restoration of my voting rights.
This authorization covers records held by any state or federal court clerk's office, the Department of Correction, the Board of Parole, any District Attorney General's office, the Department of Human Services or any child support enforcement agency, and any other county, state, or federal agency with relevant conviction, sentencing, supervision, or financial records.
A digital or electronic copy of this authorization carries the same legal validity as a physical original. This consent remains in effect for the duration of my representation by [Organization Name] unless revoked by me in writing.
By checking this box and submitting this form, I acknowledge that my electronic submission constitutes my legal signature and consent.
