IN THE ___________ COURT OF __________ COUNTY STATE OF INDIANA __________________________ Full Name of Movant __________________________ Prison Number (if any) Case No. ____________________________ (To be supplied by the clerk of the court) v. State of Indiana, Respondent. INSTRUCTIONS - READ CAREFULLY In order for this motion to receive consideration by the court, it shall be in writing (legibly handwritten or typewritten), signed by the petitioner and verified before a person authorized to administer oaths, and it shall set forth in concise form the answers to each applicable question. If necessary, petitioner may furnish his answer to a particular question on the reverse side of the page or an additional blank page. Petitioner shall make it clear to which question any such continued answer refers. This motion must be filed in the court which imposed sentence. Under the provisions of Rule PC 1, petitioner is required to include in this motion every ground known to him for vacating, setting aside or correcting his conviction and sentence. Be sure to include every ground. Since every motion must be sworn to under oath, any false statement of a material fact therein may serve as the basis of prosecution and conviction for perjury. Petitioners should therefore exercise care to assure that all answers are true and correct. If the motion is taken in forma pauperis, it shall include an affidavit (attached at the back of the form) setting forth information which establishes that petitioner will be unable to pay costs of the proceedings. When the motion is completed, the original and two copies shall be mailed to the clerk of the court from which he was sentenced. 1. Place of detention, if detained ____________________________________________________ ____________________________________________________ If not, present address ____________________________________________________ ____________________________________________________ 2. Name and location of court which, and name of judge who, imposed sentence ____________________________________________________ ____________________________________________________ 3. The case number and the offense or offenses for which sentence was imposed ____________________________________________________ ____________________________________________________ 4. The date upon which sentence was imposed and the terms of the sentence ____________________________________________________ ____________________________________________________ 5. Was the finding of guilty made: ( ) After a plea of guilty? OR ( ) After a plea of not guilty? 6. Did you appeal from the judgment of conviction? ( ) Yes ( ) No 7. If you answered "yes" to (6), list: (a) The name of the court to which you appealed: ___________________________________________________ ___________________________________________________ (b) The result in such court and the date of such result: ___________________________________________________ ___________________________________________________ 8. State concisely all the grounds known to you for vacating, setting aside or correcting your conviction and sentence. (See Rule PC 1, Sec. 1a) ________________________________________________ ________________________________________________ ________________________________________________ (b) ________________________________________________ ________________________________________________ ________________________________________________ (c) ________________________________________________ ________________________________________________ ________________________________________________ (a) (If you have more grounds, use reverse side or separate sheet. However, if this is a successive petition for post-conviction relief, you may submit no more than fifteen (15) additional pages, double-spaced, to provide supporting facts. You may also submit exhibits.) 9. State concisely and in the same order the facts which support each of the grounds set forth in (8). ________________________________________________ ________________________________________________ ________________________________________________ (b) ________________________________________________ ________________________________________________ ________________________________________________ (c) ________________________________________________ ________________________________________________ ________________________________________________ (a) 10. Prior to this petition, have you filed with respect to this conviction: (a) Any petition for post conviction relief pursuant to Rule PC 1 or PC 2? ( ) Yes ( ) No (b) Any petitions for habeas corpus in state or federal courts? ( ) Yes ( ) No (c) Any petitions in the United States Supreme Court for certiorari? ( ) Yes ( ) No (d) Any other petitions, motions or applications in this or any other court? ( ) Yes ( ) No 11. If you answered "yes" to any part of (10), list with respect to each petition, motion or application: (a) Its specific nature: i. __________________________________________________________________________ ii. __________________________________________________________________________ iii. __________________________________________________________________________ (b) The name and location of the court in which each was filed: i. __________________________________________________________________________ ii. __________________________________________________________________________ iii. __________________________________________________________________________ (c) The disposition of the petition, motion or 16 application and the date of disposition: i. __________________________________________________________________________ ii. __________________________________________________________________________ iii. __________________________________________________________________________ (d) If known, citations of any written opinions or orders entered pursuant to each disposition: i. __________________________________________________________________________ ii. __________________________________________________________________________ iii. __________________________________________________________________________ 12. Has any ground set forth in (8) been previously presented to this or any other court, state or federal, in any petition, motion or application which you have filed? ( ) Yes ( ) No 13. If you answered "yes" to (12), identify: (a) Which grounds have been previously presented: i. __________________________________________________________________________ ii. __________________________________________________________________________ iii. __________________________________________________________________________ (b) The proceedings in which each ground was raised: i. __________________________________________________________________________ ii. __________________________________________________________________________ iii. __________________________________________________________________________ 14. Were you represented by an attorney at any time during the course of: (a) Your preliminary hearing? ( ) Yes ( ) No (b) Your arraignment and plea? ( ) Yes ( ) No (c) Your trial, if any? ( ) Yes ( ) No (d) Your sentencing? ( ) Yes ( ) No (e) Your appeal, if any, from the judgment of conviction or the imposition of sentence? ( ) Yes ( ) No (f) Preparation, presentation or consideration of any petitions, motions or applications with respect to this conviction, which you filed? ( ) Yes ( ) No 15. If you answered "yes" to one or more parts of (14), list: (a) The name and address of each attorney who represented you: i. __________________________________________________________________________ ii. __________________________________________________________________________ iii. __________________________________________________________________________ (b) The proceedings at which each such attorney represented you: i. __________________________________________________________________________ ii. __________________________________________________________________________ iii. __________________________________________________________________________ (c) Was said attorney: ( ) Appointed by the court? OR ( ) Of your own choosing? 16. Have you completed service of the challenged sentence? ( ) Yes ( ) No 17. Have you retained an attorney to represent you in this proceeding? ( ) Yes ( ) No 18. If you are without sufficient funds to employ counsel and are incarcerated in the Indiana Department of Correction, the Public Defender may represent you. If you check "NO" you lose the right to representation by the State Public Defender for the duration of this proceeding, including any appeal therefrom. (a) Do you wish to have the Public Defender represent you? ( ) Yes ( ) No (b) If yes, have you completed the Affidavit of Indigency attached to this form, stating your salary, if any, amount of savings, and all property owned by you? ( ) Yes ( ) No _______________________________ Signature of Petitioner State of ___________________ County of _________________ ) ) ) SS: I, ________________, being duly sworn upon my oath, depose and say that I have subscribed to the foregoing petition; that I know the contents thereof; that it includes every ground known to me for vacating, setting aside or correcting the conviction and sentence attacked in this motion; and that the matters and allegations therein set forth are true. _______________________________ Signature of Affiant Subscribed and sworn to before me this ________ day of __________, 19__. ______________________________ Notary Public My Commission Expires: _________________ (month) (day) (year) AFFIDAVIT OF INDIGENCY (See instructions page 1 of this form) ____________________________________________________ ____________________________________________________ ____________________________________________________ ____________________________________________________ ____________________________________________________ ____________________________________________________ _________________________________ Signature of Petitioner State of __________________ County of ________________ ) ) SS: ) I, _________________________, being first duly sworn upon my oath, depose and say that I have subscribed to the foregoing affidavit; that I know the contents thereof; and that the matters therein set forth are true. _______________________________ Signature of Affiant Subscribed and sworn to before me this _________ day of ________, 19__. __________________________ Notary Public My Commission Expires: _________________ (month) (day) (year)