County Court District Court Denver Juvenile Court ___________________________County, Colorado Court Address: State of Colorado v. Defendant: _____________________________ COURT USE ONLY Case Number Attorney or Party Without Attorney (Name and Address): Phone Number: E-mail: Division Courtroom FAX Number: Atty. Reg. #: MOTION TO DETERMINE FACTUAL INNOCENCE PURSUANT TO §16-5-103, C.R.S. This Motion is for the purpose of determining factual innocence due to identity theft. 1. Information about the alleged victim of identity theft: Full Name: __________________________________________ Date of Birth: ________________________ Current Mailing Address: ___________________________________________________________________ City & Zip: ______________________________________________________________________________ Home Phone #: __________________ Work Phone #: ___________________ Cell #: __________________ 2. The following identifying information has been inappropriately obtained from the alleged victim of identity theft: Name Social security number Address Birth Date Drivers license number Bank account records Passport Driver’s license Other (specify): ____________________ Other (specify): __________________ 3. The use of identifying information above has been mistakenly associated with an arrest, summons, summons and complaint, felony complaint, information, indictment, or conviction. (Please check all that apply.) 4. Name of Arresting Agency: ________________________________________________________________ 5. Please identify specific information below and attach any affidavits, police reports, or any other relevant information: Offense Date Arrest or Summons Date Arrest or Summons Number Charge Description Case Number (identity each charge separately) Date of Conviction or indictment Charges Filed Yes/No (if applicable) 6. Following the filing of this Motion, the alleged victim of identity theft will report directly to the Colorado Bureau of Investigation or a local law enforcement agency for fingerprint verification in the CBI state database. 7. If applicable, the alleged victim of identity theft has provided a copy of this Motion to the District Attorney’s Office. Wherefore, the alleged victim of identity theft requests this Court to determine factual innocence pursuant to §165-103, C.R.S. based on the information submitted. Date: ________________________________ _____________________________________ Signature JDF 223 R7/05 MOTION TO DETERMINE FACTUAL INNOCENCE PURSUANT TO §16-5-103, C.R.S. American LegalNet, Inc. www.FormsWorkflow.com