Declaration Questionnaire
This form will help get you started on writing your declaration. You'll see that some of the questions seem repetitive – they are just different ways of helping you think about what you want to say to the judge.  

Don't forget to take a look at the samples on this page to get a sense of what other successful applicants have included.

After you fill out this questionnaire, we will send you a Word document that you can edit to revise.  When you are satisfied with your statement, email it to Jasmine and we will review it with you.  

Don't worry – filling in this form on this page is confidential.  It will not save to the page or be public in any way.  Only you and The Access Project will see your responses.

If you would like help from a volunteer, you'll have the opportunity to request that assistance below.
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Enter your phone number here. (This helps us link your responses to your Access Project file.) *
Enter your full name here *
What was happening in your life when you were arrested/convicted?   How has your criminal record hurt your life or your loved ones? *
What have you done to improve your life since your convictions?  (For example: rehab, started supporting family, got children back from foster care, got a job, got job training or education.) *
What are some ways that you live now that help you avoid arrests or convictions? (For example, being part of a church or community group that helps you, having family support, counseling, 12-step program participation, changing social groups to avoid former connections.) *
What does the court need to know about who you are today? What would you say about why granting this dismissal is the right thing to do for you, for your family, and for your community? *
Do you belong to any social or religious organizations?  Do you volunteer at any organizations? (For example, being active in your church, volunteering at your children’s school, coaching kids’ sports, being a sponsor, regularly attending 12-step program meetings.) *
Why do you want to clean up your record? What would be different in your life if you had a clean slate? (For example, being able to get a new job or different housing, applying for state license, putting past behind you, feeling of personal dignity and accomplishment.) *
Who in your life would support this application? Clergy? Family? Supervisor? Sponsor? Volunteer organization? Are you willing to ask any of those people to write a letter to support you?  Please list them here and tell us your relationship with them. *
Do you have any certificates or school transcripts that would support your application?  (For example, completion of job training, employee appreciation, volunteer certification, transcripts from education.). If so, make notes of what you want to gather here. *
Would you like someone to help you draft your declaration?  (We will review and help edit declarations for EVERYONE.  Please ask for help here only if you feel you need special assistance.)
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Please provide the email where you would like to receive the draft you just created! *
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