UNITED STATES DISTRICT COURT FOR THE NORTHERN DISTRICT OF CALIFORNIA MOTION, PURSUANT TO SECTION 2255 OF TITLE 28 UNITED STATES CODE ATTACKING A SENTENCE IMPOSED BY THAT COURT UNITED STATES OF AMERICA VS. CASE NO. (To be supplied by the Clerk of the District Court) (name of movant) (Full name under which you were convicted) ____________________________________________________________________________ INSTRUCTIONS-READ CAREFULLY In order for this motion to receive consideration by the District Court, it shall be in writing (legibly handwritten or typewritten) by the Movant, under penalty of perjury, and it shall set forth in concise form the answers to each applicable question. If necessary, Movant may finish his answer to a particular question on the reverse side of the page or on an additional blank page. Movant shall make it clear to which question any such continued answer refers. Since every motion under Section 2255 of Title 28, United States Code, must be made under penalty of perjury, any false statement of a material fact therein may serve as the basis of prosecutions and conviction for perjury. Movant should therefore exercise care to assure that all answers are true and correct. If the motion is made in forma pauperis, it shall include an affidavit (page 6 of this form) setting forth information which establishes that the Movant will be unable to pay the fees and costs of the 2255 proceedings. When the form is completed, the original and 2 copies shall be mailed to 1 2002 © American LegalNet, Inc. the Clerk of the District Court for the Northern District of California, 450 Golden Gate Avenue, San Francisco, CA 94102. 1. Place of detention ___________________________________________________________ 2. Name and location of Court which, and name of judge who, imposed sentence ___________ ____________________________________________________________________________ 3. The indictment number or numbers (if known) upon which the offense or offenses for which sentence was imposed.: (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) after a plea of guilty ___________________________________________________ (b) after a plea of not guilty ________________________________________________ (c) After a plea of nolo contenders __________________________________________ 6. If you were found guilty after a plea of not guilty, check whether that finding was made by (a) a jury (b) a judge without a jury ___________________________________ ___________________________________ 7. Did you appeal from the judgment of conviction or the imposition of sentence? ___________ 8. If you answered "yes" to question 7, list (a) the name of each court to which you appealed: I 11 111 ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ (b) the result of each such court to which you appealed: 2 2002 © American LegalNet, Inc. I 11 111 ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ (c) the date of each such result: I 11 111 ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ (d) If known, citations of any written opinions or orders entered pursuant to such results: I 11 111 ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ 9. State concisely the grounds on which you base your allegation that the sentence which was imposed on you is invalid. (a) ____________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ (b) ___________________________________________________________________ ____________________________________________________________________________ ___________________________________________________________________________ (c) ____________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ 10. State concisely and in the same order the facts which support each of the grounds set out in (9): (a) ____________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ (b) __________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ (c) ____________________________________________________________________ 3 2002 © American LegalNet, Inc. ____________________________________________________________________________ ____________________________________________________________________________ 11. Have you previously filed petitions for habeas corpus motions under section 2255 of Title 28, United States Code, or any other applications, petitions or motions with respect to this conviction? __________ 12. If you answered "yes" to (11), list with respect to each petition, motion or application (a) the specific nature thereof: I 11 111 ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ (b) the name and location of the court in which each was filed: I 11 111 ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ (c) the disposition thereof: I 11 111 ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ (d) the date of each disposition I 11 111 ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ (e) if known, citations of any written opinions or orders entered pursuant to each such disposition: I 11 111 ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ 13. Has any ground set forth in (9) been previously presented to this or any other federal court by way of petition for habeas corpus, motion under section 2255 of Title 28, United States Code, or any other petition, motion or application? ________________________ 14. If you answered "yes" to (13), identify (a) which grounds have been previously presented: 4 2002 © American LegalNet, Inc. I 11 111 ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ (b) the proceedings in which each ground was raised: I 11 111 ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ 15. Were you represented by an attorney at any time during the course of (a) your arraignment and plea? ______________________ (b) your trial, if any? ______________________ (c) your sentencing? ______________________ (d) your appeal, if any, from the judgment of conviction of the imposition of sentence? ______________________ (e) preparation, presentation or consideration of any petitions, motions or applications with respect to this conviction, which you filed? ____________________ 16. If you answered "yes" to one or more parts of (15), list (a) the name and address of each attorney who represented you: I 11 111 ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ WHEREFORE, movant prays that the Court grant movant relief to which he may be entitled in this proceeding. Signed under penalty of perjury __________________________________________ at ____________ __________________________________ _____________________________________ Date Signature of Movant 5 2002 © American LegalNet, Inc. IN THE UNITED STATES DISTRICT COURT FOR THE NORTHERN DISTRICT OF CALIFORNIA _____________________________________, Plaintiff, CASE NO. v.. APPLICATION TO PROCEED IN FORMA PAUPERIS _____________________________________, Defendant. I, _______________________________________, declare, under penalty of perjury that I am the plaintiff in the above entitled case and that the information I offer throughout this application is true and correct. I offer this application in support of my request to proceed without being required to prepay the full amount of fees, costs or give security. I state that because of my poverty I am unable to pay the costs of this action or give security, and that I believe that I am entitled to relief. In support of this application, I provide the following information: 1. Are you presently employed? Yes _______ No _______ If your answer is "yes", state both your gross and net salary or wages per month, and give the name and address of your employer: Gross: _____________________________________ Net: _____________________________ Employer: ___________________________________________________________________________ If the answer is “no”, state the date of last employment and the amount of the gross and net salary and wages per month which you received. (If you are imprisoned, specify the last place of employment prior to imprisonment.) ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ 2. Have you received, within the past twelve (12) months, any money from any of the following sources: 6 2002 © American LegalNet, Inc. a) Business, profession or self employment Yes _______ No _______ b) Income from stocks, bonds, or royalties? Yes _______ No _______ c) Rent payments? Yes _______ No _______ d) Pensions, annuities, or life insurance payments? Yes _______ No _______ e) Federal or State welfare payments, Social Security or other government source? Yes _______ No _______ If the answer is "yes" to any of the above, describe each source of money and state the amount received from each. ____________________________________________________________ ____________________________________________________________________________ 3. Are you married? Yes _______ No _______ Spouse’s Full Name: ___________________________________________________________ Spouse’s Place of Employment: __________________________________________________ Spouse’s Monthly Salary, Wages or Income: Gross $ __________________________ Net $ _______________________ 4. a) List amount you contribute to your spouse's support: $ ___________________________________________________________________________ b) List the persons other than your spouse who are dependent upon you for support and indicate how much you contribute toward their support: ____________________________________________________________________________ ____________________________________________________________________________ 5. Do you own or are you buying a home? Yes _______ No _______ Estimated Market Value: $ ________________ Amount of Mortgage:$_______________ 6. Do you own an automobile? Make: ____________________ Yes _______ No _______ Year: __________ Model:_____________________ 7 2002 © American LegalNet, Inc. Is it financed? Yes _______ No _______ If so, Total due: $____________________ Monthly Payment: $_______________________ 7. Do you have a bank account? (If you are a prisoner, include funds in your prison account, and provide the certificate attached, verified by an officer of the prison.) Yes _______ No _______ Name (s) and address (es) of bank: ________________________________________________ ____________________________________________________________________________ Present balance (s) : $___________________________________________________________ Do you own any cash? Yes _______ No _______ Amount: $ _____________ Do you have any other assets? (If "Yes", provide a description of each asset and its estimated market value) . Yes _______ No _______ ____________________________________________________________________________ 8. What are your monthly expenses? Rent: $_________________ Food: $_________________ Utilities: $_________________ Clothing: $_________________ Charge Accounts: Name of Account _________________________ _________________________ _________________________ Monthly Payment _______________ _______________ _______________ Total owed On This Account _______________________ _______________________ _______________________ 9. Do you have any other debts? (List current obligations, indicating amounts and to whom they are payable.) ____________________________________________________________________________ _____________________________________________________________________________ 10. Does the complaint which you are seeking to file raise claims that have been presented in other lawsuits? Yes _______ No _______ Please list the case name (s) and number (s) of the prior lawsuit (s) ,and the name of the court in which they were filed. 8 2002 © American LegalNet, Inc. _____________________________________________________________________________ _____________________________________________________________________________ I declare under the penalty of perjury that the foregoing is true and correct and understand that a false statement herein may result in the dismissal of my claims. Date: ________________ Signature of Applicant:____________________________ 9 2002 © American LegalNet, Inc. CERTIFICATE OF FUNDS IN PRISONER’S ACCOUNT I certify that attached hereto are true and correct copies of the prisoner account transactions of _____________________________________________________________________________ at ___________________________________________________________________________ where (s)he is confined. _____________________________________________________________________________ Authorized Officer of the Institution 10 2002 © American LegalNet, Inc.