PETITION FOR WRIT OF HABEAS CORPUS BY A PERSON IN FEDERAL CUSTODY (28 U.S.C 247 2241)CV-27 (0/)Page 1 of 7 NAME PRISON IDENTIFICATION/BOOKING NO. ADDRESS OR PLACE OF CONFINEMENT Note:If represented by an attorney, provide name, address & telephonenumber. It is your responsibility to notify the Clerk of Court inwriting of any change of address.UNITED STATES DISTRICT COURTCENTRAL DISTRICT OF CALIFORNIA FULL NAME (Include name under which you were convicted)Petitioner, v. NAME OF WARDEN, (or other authorized person having custody ofpetitioner)Respondent.CASE NUMBER:CV To be supplied by the Clerk of the United States District CourtCR Criminal case under which sentence was imposed.PETITION FOR WRIT OF HABEAS CORPUS BY A PERSON IN FEDERAL CUSTODY(28 U.S.C 247 2241) INSTRUCTIONS - READ CAREFULLYThis petition shall be legibly handwritten or typewritten signed by of perjury. You must set forthCONCISELY the answer to each question in the proper space on the form. Any false statement of fact may serveas the basis for prosecution and conviction for perjury.You must not attach separate pages to this petition except that ONE separate additional page is permitted in answeringQuestion No.9.Upon receipt of a fee of $5.00 your petition will be filed if it is in proper order.If you are seeking leave to proceed in forma pauperis (without paying the $5.00 filing fee and other court costs), then youmust also execute the declaration on the last page, setting forth information establishes your inability to pay the feesand costs of the proceedings or to give security therefor. If you wish to proceed , you must have anauthorized officer at the penal institution complete the certificate as to the amount of money and securities on deposit to yourcredit in any account in the institution. If your prison account exceeds $25.00, you must pay the filing fee as required by therule of the district court.When the petition is completed, the original and 3 copies must be mailed to the Clerk of the United States District Court forthe Central District of California, Courthouse, Street, Los Angeles, California 90012,ATTENTION: Intake/Docket Section.Only one sentence, conviction or parole matter may be challenged in a single petition. If you challenge more than one, youmust do so by separate petitions. American LegalNet, Inc. www.FormsWorkFlow.com PETITION FOR WRIT OF HABEAS CORPUS BY A PERSON IN FEDERAL CUSTODY (28 U.S.C 247 2241)Page 2 of 7 PLEASE COMPLETE THE FOLLOWING: (Check appropriate number)This petition concerns:1.G a conviction.2.G a sentence.3.G jail or prison conditions.4.G prison discipline.5.G a parole problem.6.G other.PETITION Place of detentionName and location of court imposed sentence 3.The indictment number or numbers (if known) upon which, and the offense or offenses for which, sentence wasimposed:a. b. c. 4.The date upon which sentence was imposed and the terms of the sentence:a. b. c. 5.Check whether a finding of guilty was made:a.G After a plea of guiltyb.G After a plea of not guiltyc.G After a plea of nolo contendere6.If you were found guilty after a plea of not guilty, check whether that finding was made by:a.G a juryb.G a judge without a jury7.Did you appeal from the judgment of conviction or the imposition of sentence? G Yes G No8.If you did appeal, give the following information for each appeal:CAUTION:If you are attacking a sentence imposed under a federal judgment, you must first file a direct appeal ormotion under 28 U.S.C. 247 2255 in the federal court that entered the judgment.a.(1) Name of court (2)Result (3)Date of result (4)Citation or number of opinion American LegalNet, Inc. www.FormsWorkFlow.com PETITION FOR WRIT OF HABEAS CORPUS BY A PERSON IN FEDERAL CUSTODY (28 U.S.C 247 2241)Page 3 of 7 (5)Grounds raised (list each):(a) (b) (c) (d) b.(1)Name of court (2)Result (3)Date of result (4)Citation or number of opinion (5)Grounds raised (list each):(a) (b) (c) (d) 9.State CONCISELY every ground on which you claim that you are being held unlawfully. Summarize briefly thefacts supporting each ground. If necessary, attach a SINGLE page only behind this page.CAUTION:If you fail to set forth all grounds in this petition, you may be barred from presenting additionalgrounds at a later date. You must state facts, not conclusions, in support of your grounds. A rule ofthumb to follow: state WHO did exactly WHAT to violate your rights at WHAT time and place.a.Ground one: Supporting FACTS (tell your story BRIEFLY without citing cases or law): b.Ground two: Supporting FACTS (tell your story BRIEFLY without citing cases or law): American LegalNet, Inc. www.FormsWorkFlow.com PETITION FOR WRIT OF HABEAS CORPUS BY A PERSON IN FEDERAL CUSTODY (28 U.S.C 247 2241)Page 4 of 7 c.Ground three: Supporting FACTS (tell your story BRIEFLY without citing cases or law): d.Ground four: Supporting FACTS (tell your story BRIEFLY without citing cases or law): Have you filed previous petitions for habeas corpus, motions under Section 2255 of Title 28, United States Code, orany other applications, petitions or motions with respect to this conviction? G Yes G NoIf your answer to Question No. 10 was yes, give the following information:(1)Name of CourtNature of proceedingGrounds raised (4)Result (5)Date of result (6)Citation or number of any written opinions or orders entered pursuant to each disposition. American LegalNet, Inc. www.FormsWorkFlow.com PETITION FOR WRIT OF HABEAS CORPUS BY A PERSON IN FEDERAL CUSTODY (28 U.S.C 247 2241)Page 5 of 7 b.(1)Name of Court (2)Nature of proceeding (3)Grounds raised (4)Result (5)Date of result (6)Citation or number of any written opinions or orders entered pursuant to each disposition. 12.If you did not file a motion under Section 2255 of Title 28, United States Code, or if you filed such a motion and itwas denied, state why your remedy by way of such motion is inadequate or ineffective to test the legality of yourdetention: 13.Are you presently represented by counsel? G YesG No If so, provide name, address and telephone number Case name and court 14.If you are seeking leave to proceed , have you completed the declaration setting forth the required information? G YesG NoWHEREFORE, petitioner prays that the court grant petitioner relief to which he may be entitled in this proceeding, Signature of Attorney (if any)I declare (or certify, verify, or state) under penalty of perjury that the foregoing is true and correct.Executed on DateSignature of Petitioner American LegalNet, Inc. www.FormsWorkFlow.com PETITION FOR WRIT OF HABEAS CORPUS BY A PERSON IN FEDERAL CUSTODY (28 U.S.C 247 2241)Page 6 of 7 Petitioner Respondent(s) DECLARATION IN SUPPORTOF REQUESTTO PROCEED I, , declare that I am the petitioner in the above entitledcase; that in support of my motion to proceed without being required to prepay fees, costs or give security therefor, I statethat because of my poverty I am unable to pay the costs of said proceeding or to give security therefor; that I believe I amentitled to relief.1.Are you presently employed? G Yes G Noa.If the answer is yes, state the amount of your salary or wages per month, and give the name and address of youremployer. b.If the answer is no, state the date of last employment and the amount of the salary and wages per month whichyou received. 2.Have you received, within the past twelve months, any money from any of the following sources?a.Business, profession or form of self-employment?GYes G Nob.Rent payments, interest or dividends?GYes G Noc.Pensions, annuities or life insurance payments?GYes G Nod.Gifts or inheritances?GYes G Noe.Any other sources?GYes G NoIf the answer to any of the above is yes, describe each source of money and state the amount received from eachduring the past twelve months: 3.Do you own any cash, or do you have money in a checking or savings account? (Include any funds in prisonaccounts)G Yes G NoIf the answer is yes, state the total value of the items owned: 4.Do you own any real estate, stocks, bonds, notes, automobiles, or other valuable property? (Excluding ordinaryhousehold furnishings and clothing) G Yes G NoIf the answer is yes, describe the property and state its approximate value: Ameri