STATE OF CALIFORNIA DEPARTMENT OF JUSTICECJIS 4046D (Rev. 01/2020)

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APPLICATION FOR EXCLUSION FROM INTERNET DISCLOSURE

California Penal Code (Pen. Code) Section (§) 290.46 Please print or type the required information. Illegible or incomplete information, or the lack of required documentation, may delay the processing of this application and may result in denial of your application. Mail this completed application, together with all necessary supporting documentation to:

FULL NAME Last First Middle

DATE OF BIRTH DRIVER'S LICENSE/I.D. NUMBER SOCIAL SECURITY NUMBER

ADDRESS Number and Street (P.O. Boxes will not be accepted)

CITY ZIP CODE PHONE NUMBER (Include Area Code)

Felony conviction of Pen. Code, § 243.4(a) (no documents required).Misdemeanor conviction of Pen. Code, § 647.6 – formerly Pen. Code, § 647a (no documents required).

Felony conviction of Pen. Code, §§ 311.1, 311.2 subd. (b), (c), or (d), or 311.3, 311.4, 311.10, or 311.11. Submit a certified copy of a probation report filed in court that clearly states that all victims involved in the commission of the offense were at least sixteen (16) years of age or older at the time of the commission of the offense.

IMPORTANT: If you were adjudicated a sexually violent predator pursuant to Welfare and Institutions Code § 6600, et seq., you cannot apply for exclusion from the Megan's Law Internet site. If your most recent Static – 99R score is higher than 3, you are not eligible for exclusion. Basis for exclusion (Please check one that applies):

SIGNATURE DATE

California Department of Justice ATTN: California Sex Offender Registry

P.O. Box 903387 Sacramento, CA 94203-3870

Based upon a review of your criminal history record and submitted supporting documentation, the DOJ will determine whether you meet the requirements for exclusion from disclosure on the Megan's Law Internet site. Please ensure that only copies of your documentation are sent and not the originals. Documentation submitted to the DOJ will not be returned to the applicant. Pursuant to Pen. Code, § 290.46(e), I hereby apply to be excluded from disclosure on the Megan's Law Internet site. I certify under the laws of the State of California that the foregoing is true and correct. I understand that I am still required to register, which is a lifetime requirement, and comply with all of the provisions set forth in Pen. Code, §§ 290–290.024, as well as all other applicable laws.

Questions concerning completion of this application may be directed to the California Sex Offender Registry at (916) 210-3113.

NOTE: Pursuant to Pen. Code, § 290.46(e)(3), if the department determines that a person who was granted exclusion under a former version of Pen. Code, § 290.46(e) would not qualify for exclusion under an updated version of this subdivision, the department is mandated by law to rescind the exclusion, make a reasonable effort to provide notification to the person that the exclusion has been rescinded, and no sooner than thirty (30) days after notification is attempted, make information about the offender available to the public on the Internet Web site.

Suffix

STATE

Conviction of a registrable offense (Pen. Code, §§ 290–290.006) with proof of successful completion of probation or that you are currently on probation. Submit to the Department of Justice (DOJ) a certified copy of a probation report, pre-sentence report, report prepared pursuant to Pen. Code, § 288.1, or court documentation that demonstrates both the following: 1) You were the victim's parent, stepparent, sibling, or grandparent; and 2) The crime did not involve either oral copulation or any type of penetration.

STATE OF CALIFORNIA DEPARTMENT OF JUSTICECJIS 4046D (Rev. 01/2020)

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REGISTERED SEX OFFENDER ELIGIBILITY FOR EXCLUSION FROM INTERNET SITE

You may apply for exclusion from the Megan's Law Internet site if the following conditions apply: 1. You were convicted of one or more of the following offenses: • A felony conviction of Pen. Code, § 243.4, subdivision (a) – Sexual Battery. (No documents required) • A misdemeanor conviction of Pen. Code, § 647.6, (formerly section 647a) – Annoy or molest a child. (No documents required) • Conviction of a registrable offense (Pen. Code, §§ 290–290.006) with proof of successful completion of probation or that you are currently on probation. Submit to the DOJ a certified copy of a probation report, pre-sentencing report, report prepared pursuant to Pen. Code, § 288.1, or court documentation that demonstrates both the following: 1) You were the victim's parent, stepparent, sibling, or grandparent; and 2) The crime did not involve either oral copulation or penetration of the vagina or rectum of either the victim or the offender by the penis of the other or by any foreign object. • A felony conviction of Pen. Code, §§ 311.1, 311.2 subd. (b), (c), or (d), or 311.3, 311.4, 311.10, or 311.11. Submit a certified copy of a probation report filed in court that clearly states that all victims involved in the commission of the offense were at least sixteen (16) years of age or older at the time of the commission of the offense. 2. During the period of probation, you did not receive additional incarceration time for a violation or probation, nor were you convicted of another offense resulting in a sentence to county jail or state prison. If, subsequent to your application, you commit a violation of probation resulting in incarceration in county jail or state prison, you will be reposted on the public Megan's Law Internet site. ACCEPTABLE DOCUMENTATION In certain cases, in order for the DOJ to evaluate your application, you must also submit supporting documentation. IMPORTANT: Please ensure that only copies of your documentation are sent and not the originals. Documentation

submitted to the DOJ will not be returned to the applicant. Sources where this information can be obtained and the types of documents that the DOJ will accept include: • Probation Department – Probation officer report, pre-sentencing report, or letter from your supervising probation department. • Court – Court report prepared pursuant to Pen. Code, § 288.1 or other official court documentation. If you are obtaining a letter from one of the above sources, it must be written on departmental letterhead and signed by an appropriate official.

STATE OF CALIFORNIA DEPARTMENT OF JUSTICECJIS 4046D (Rev. 01/2020)

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APPLICATION FOR EXCLUSION FROM INTERNET DISCLOSURE

California Penal Code (Pen. Code) Section (§) 290.46

Privacy Notice As Required by Civil Code § 1798.17

Collection and Use of Personal Information. The California Justice Information Services (CJIS) Division of the Department of Justice (DOJ) collects the information requested on this form as authorized by Pen. Code, § 290.46. The CJIS Division uses this information to identify the registered sex offender applying for exclusion from the Megan's Law Internet site. In addition, any personal information collected by state agencies is subject to the limitations in the Information Practices Act and state policy. The DOJ's general privacy policy is available at https://oag.ca.gov/privacy-policy. Providing Personal Information. All the personal information requested in the form must be provided. Failure to provide the mandatory personal information will result in your application being denied. Access to Your Information. You may review the records maintained by the CJIS Division that contain your personal information, as permitted by the Information Practices Act. See below for contact information. Possible Disclosure of Personal Information. Pursuant to Pen. Code, § 290.022, the DOJ is required by law to provide law enforcement agencies with the information you give us. The information you provide may also be disclosed in the following circumstances: • With other persons or agencies where necessary to perform their legal duties, and their use of your

information is compatible and complies with state law, such as for investigations or for licensing, certification, or regulatory purposes;

• To another government agency as required by state or federal law.

Contact Information. For questions about this notice or information on your registrant record, you may contact the California Sex Offender Registry manager by phone at (916) 210-3113, by e-mail at MegansLaw@doj.ca.gov, or via mail at:

The Department of Justice

California Sex Offender Registry P.O. Box 903387

Sacramento, CA 94203-3870

I have read and understand the Privacy Notice as required by Civil Code § 1798.17

SIGNATURE DATE