County Court District Court Denver Juvenile Court ___________________________County, Colorado Court Address:  State of Colorado COURT USE ONLY v. Defendant: _____________________________ Attorney or Party Without Attorney (Name and Address): Case Number Phone Number: ____________ E-mail:________________________ FAX Number:______________ Atty. Reg. #: ________________ Division _______ Courtroom ______ MOTION TO DETERMINE FACTUAL INNOCENCE This Motion is submitted pursuant to §16-5-103, C.R.S. 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, State & 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. 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) JDF 223 R2/10 MOTION TO DETERMINE FACTUAL INNOCENCE PURSUANT TO §16-5-103, C.R.S. Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com 6. If 7. If applicable, attached are copies of documents that support my whereabouts during the date and time of applicable, attached are copies of documents that verify my identity, e.g. social security card, birth certificate, passport. the offense. friend, etc. 8. This may include; airline tickets, military records, a notarized statement from an employer, 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 §16-5-103, C.R.S. based on the information submitted. Date: ________________________________ _____________________________________ Signature JDF 223 R2/10 MOTION TO DETERMINE FACTUAL INNOCENCE PURSUANT TO §16-5-103, C.R.S. Page 2 of 2 American LegalNet, Inc. www.FormsWorkFlow.com