B. Every petition filed by a prisoner seeking a writ of habeas corpus shall be filed on a form to be approved and provided by the office of the Attorney General, the contents of which shall be substantially as follows: IN THE............................................................. COURT
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Full name and prisonerCase No.............................
number (if any) of(To be supplied by
Petitionerthe Clerk of the
-vs-Court)
...........................................................................
...........................................................................
Name and Title of Respondent
PETITION FOR WRIT OF HABEAS CORPUS
Instructions--Read Carefully
In order for this petition to receive consideration by the Court, it must be legibly handwritten or typewritten, signed by the petitioner and verified before a notary or other officer authorized to administer oaths. It must set forth in concise form the answers to each applicable question. If necessary, petitioner may finish his answer to a particular question on an additional page. Petitioner must make it clear to which question any such continued answer refers. The petitioner may also submit exhibits.
Since every petition for habeas corpus must be sworn to under oath, any false statement of a material fact therein may serve as the basis of prosecution and conviction for perjury under § 18.2-434. Petitioners should, therefore, exercise care to assure that all answers are true and correct.
When the petition is completed, the original and two copies (total of
three) should be mailed to the clerk of the court. The petitioner shall keep one copy.
NOTICE
The granting of a writ of habeas corpus does not entitle the petitioner to dismissal of the charges for conviction of which he is being detained, but may gain him no more than a new trial.
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Place of detention:.....................................................
A. Criminal Trial 1. Name and location of court which imposed the sentence from which you seek relief:...................................................................................................................................................2. The offense or offenses for which sentence was imposed (include indictment number or numbers if known): a ....................................................................b ....................................................................c ....................................................................3. The date upon which sentence was imposed and the terms of the sentence:a ....................................................................b ....................................................................c ....................................................................4. Check which plea you made and whether trial by jury: Plea of guilty: .......; Plea of not guilty:.......; Trial by jury:......; Trial by judge without jury:....5. The name and address of each attorney, if any, who represented you at your criminal trial:......................................................................................................................................................6. Did you appeal the conviction?.......................................7. If you answered "yes" to 6, state: the result and the date in your appeal or petition for certiorari: a ....................................................................b ....................................................................citations of the appellate court opinions or orders:
a ....................................................................b ....................................................................8. List the name and address of each attorney, if any, who represented you on your appeal:......................................................................................................................................................B. Habeas Corpus 9. Before this petition did you file with respect to this conviction any other petition for habeas corpus in either a State or federal court?.......10. If you answered "yes" to 9, list with respect to each petition: the name and location of the court in which each was filed: a.................................................................b....................................................................the disposition and the date:
a....................................................................b....................................................................the name and address of each attorney, if any, who represented you on your habeas corpus:
a....................................................................b....................................................................11. Did you appeal from the disposition of your petition for habeas corpus?12. If you answered "yes" to 11, state: the result and the date of each petition:a ....................................................................b ....................................................................citations of court opinions or orders on your habeas corpus petition:
a ....................................................................b ....................................................................the name and address of each attorney, if any, who represented you on appeal of your habeas corpus:
a ....................................................................b ....................................................................C. Other Petitions, Motions or Applications 13. List all other petitions, motions or applications filed with any court following a final order of conviction and not set out in A or B. Include the nature of the motion, the name and location of the court, the result, the date, and citations to opinions or orders. Give the name and address of each attorney, if any, who represented you. a ....................................................................b ....................................................................c ....................................................................D. Present Petition 14. State the grounds which make your detention unlawful, including the facts on which you intend to rely: a ....................................................................b ....................................................................c ....................................................................15. List each ground set forth in 14, which has been presented in any other proceeding:a ....................................................................b ....................................................................c ....................................................................List the proceedings in which each ground was raised:
a ....................................................................b ....................................................................c ....................................................................16. If any ground set forth in 14 has not been presented to a court, list each ground and the reason why it was not: a ....................................................................b ....................................................................c ..................................................................................................................
Signature of Petitioner
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Address of Petitioner
STATE OF VIRGINIA
CITY/COUNTY OF....................................
The petitioner being first duly sworn, says:
1. He signed the foregoing petition;2. The facts stated in the petition are true to the best of his information and belief. ..............................................
Signature of Petitioner
Subscribed and sworn to before me
this .. day of........................., 20....
..................................... Notary Public
My commission expires:.......................
The petition will not be filed without payment of court costs unless the petitioner is entitled to proceed in forma pauperis and has executed the affidavit in forma pauperis.
The petitioner who proceeds in forma pauperis shall be furnished, without cost, certified copies of the arrest warrants, indictment and order of his conviction at his criminal trial in order to comply with the instructions of this petition.
AFFIDAVIT IN FORMA PAUPERIS
STATE OF VIRGINIA
CITY/COUNTY OF..............................
The petitioner being duly sworn, says:
1. He is unable to pay the costs of this action or give security therefor;2. His assets amount to a total of $..................... ..............................................
Signature of Petitioner
Subscribed and sworn to before me
this .. day of........................., 20....
..................................... Notary Public
My commission expires:...................