APPENDIX B POST-CONVICTION HABEAS CORPUS FORM APPLICATION TO PROCEED IN FORMA PAUPERIS AND AFFIDAVIT County STATE OF WEST VIRGINIA Name Prisoner No. Case No.Place of Confinement Name of Petitioner (include name under which convicted) Name of Respondent (authorized person having custody of petitioner) v. NOTICE: This form is only to be used by incarcerated persons seeking post-conviction habeas corpus relief pursuant to W. Va. Code 53-4A-1, et seq. I, ______________________________________________________________ declare that I am the petitioner in the above-entitledproceeding; that in support of my request to proceed without prepayment of fees or costs, I declare that I am unable to pay the costsof these proceedings and that I am entitled to the relief sought in the petition. In support of this application, I answer the following questions under penalty of perjury: 1. State the place of your incarceration ______________________________________________________________________. Are you employed at the institution? __________ Do you receive any payment from the institution? __________ Have the institution fill out the Certificate portion of this application and attach a ledger sheet from the institution(s) of your incarceration showing at least the past six months transactions. 2. In the past twelve months have you received any money from any of the following sources? a. Business, profession or other self-employment Yes No b. Rent payments, interest or dividends Yes No c. Pensions, annuities or life insurance payments Yes No d. Disability or workers compensation payments Yes No e. Gifts or inheritances Yes No f. Any other sources Yes No If the answer to any of the above is Yes describe each source of money and state the amount received and what you expect you will continue to receive. >>>> 23. Other than any institutional accounts, do you have any cash, checking or savings accounts? Yes No If Yes state the total amount___________________________________________________________________________. 4. Do you own any real estate, stocks, bonds, securities, other financial instruments, automobiles or other valuable property? Yes No If Yes describe the property and state its value. _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ 5. List the persons who are dependent on you for support, state your relationship to each person and indicate how much you contribute to their support. _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ I declare under penalty of perjury that the above information is true and correct. __________________________________ _____________________________________________________ DATE SIGNATURE OF APPLICANT CERTIFICATE (To be completed by the institution of incarceration) I certify that the applicant named herein has the sum of $____________________________ in a trustee spending account to his/her creditat (name of institution) ______________________________________________________________. I further certify that during the pastsix months the applicants average balance was $____________________________, and the average of monthly deposits was $____________________________. __________________________________ _____________________________________________________ DATE SIGNATURE OF AUTHORIZED OFFICER