COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : : Index No. Calendar No. : INSTRUCTIONS FOR PERSONS FILINGJUDICIAL SUBPOENA A PRO SE Plaintiff(s) PETITION FOR WRIT OF HABEAS CORPUS UNDER 28 U.S.C. §2241 -against- : This packet includes three copies of a form petition and two copies of an in forma pauperis motion. There : are instructions to help you understand the forms and a little bit about Court procedures, but THE COURT CANNOT GIVE YOU LEGAL ADVICE. The Court may not: accept your petition for filing unless you follow these instructions and provide the information requested in these forms. Defendant(s) : ...................................................... Is this form for you? Generally, §2241 should not be used YORK THE PEOPLE OF THE STATE OF NEW to challenge a criminal conviction or sentence. State prisoners seeking to challenge a conviction or sentence can seek relief under 28 U.S.C. §2254. Federal prisoners seeking to challenge a conviction or sentence can seek relief under 28 U.S.C. §2255. This form is not TO designed for use by persons seeking to challenge a criminal conviction or sentence, nor by those seeking to challenge an immigration decision. It may be used by persons who wish to challenge the validity of their detention on other grounds (for example, challenges to the calculation of a release date). Persons in State GREETINGS: custody should note that this Court only has jurisdiction over claims that they are in custody in violation of the laws or Constitution of the United States. and excuses being laid aside, you and each of you attend before WE COMMAND YOU, that all business , the Honorable at the Court located at County of How to file a petition in room , on the day of , 20 , at o'clock in the noon, and at any recessed or adjourned date, to testify and give evidence as a witness in this action on the part of the To begin a lawsuit you must file an original and one copy of your petition with the court. You should keep a copy of the petition for your own records. The Court is not responsible for providing copies to you. ALL COPIES MUST BE IDENTICAL TO THE ORIGINAL. Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to the party on whose behalf this subpoena was issued foryou need more space to answer a question yousustained as a Your petition must be legibly handwritten or typed. If a maximum penalty of $50 and all damages may result of your failure to comply. write on the back of the form or attach additional pages. All pages should be 8 ½” by 11". Witness, Honorable , one of the Justices of the Generally, the Respondent is the warden or administrator of the facility where you are detained. In some Court in County, day of , 20 cases, there may be other respondents. Answer the questions about related cases and prison grievances carefully. above and type name below) of You may attach copies (Attorney must sign decisions by other courts, grievances, administrative complaints, and responses to your petition. FAILING TO PROVIDE THE INFORMATION REQUESTED MAY RESULT IN YOUR PETITION NOT BEING FILED OR CAUSE DELAYS IN PROCESSING YOUR PETITION. Attorney(s) for In your petition state the facts of your case. Focus on who, what, when, where. Specify what relief you want the Court to order. The most Office andrelief sought is an order that the common P.O. Address petitioner be released. Certain other types of relief such as an order for a new hearing in front of an administrative agency may be available in particular cases. Money damages are not available in a habeas 8/99 Telephone No.: Facsimile No.: E-Mail Address: Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : Index No. : corpus action. Plaintiff(s) -against- Calendar No. : JUDICIAL SUBPOENA : When the forms are completed mail the original and one copy to: Clerk, United States District Court for the District of Maryland, 101 West Lombard Street, Baltimore,: Maryland 21201. How to ask for the filing fee to :be waived Defendant(s) : . .There. is.a. fee. of $5.00. for. filing .this. type.of. lawsuit. . This. must .be paid at the time your petition is filed. If .... . .. ...... .. .... .. ... . ...... ... .... . you are unable to pay the filing fee you may ask the Court to let you proceed in forma pauperis. The practice of this Court is that a motion for leave to proceed in forma pauperis will not be granted if, after paying the filing THE STATE OF NEW YORK THE PEOPLE OF fee, you would have $25.00 or more left in your institutional account. Attached are two copies of a motion and affidavit for leave to proceed in forma pauperis. One should be filed with your petition. The other is for your records. TO Things to know about representing yourself GREETINGS: There are procedural rules which may apply to this action. Although there are no rules specifically governing habeas corpus petitions underbusiness and excuses being laid aside, you and each ofGoverning before WE COMMAND YOU, that all 28 U.S.C. §2241, this Court usually applies the Rules you attend , the Honorable at the Habeas Corpus Cases Under Section 2254. The Federal Rules of Court Procedure will apply in some Civil located at of this Court. County of circumstances, as well as the Local Rules in room , on the day of , 20 , at o'clock in the noon, and at any recessed or adjourned date, to testify and give evidence as a witness in this action on the part of the Once your petition is received by the Court it will be reviewed and, if you have properly completed the forms and provided all necessary information, a case number and judge will be assigned. Everything that you receive from the Court about your case will have the case number on it. Everything that you send to Your failure to petition and this subpoena is punishable as in forma pauperis should have the you the Court other than thecomply with motion and affidavit to proceeda contempt of court and will makecase liable to the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a number on it. result of your failure to comply. Unless directed otherwise, all communications to the Court about your case should be addressed to: Witness, Honorable Court in County, , one of the Justices of the day of , 20 Clerk of the Court United States District Court 101 West Lombard Street Baltimore, Maryland 21201 (Attorney must sign above and type name below) You must notify the Court in writing of any change in your address. for Attorney(s) Failure to do this may result in dismissal of your case. After you file the petition no communication about your case should be sent directly to any judge. If you want to ask the Court to do something, you should file a motion. Pleadings and motions should be filed Office and P.O. Address with the Clerk and a copy should be mailed to the attorney representing the respondent(s) or directly to the respondent(s) if he/she does not have an attorney. It is important to include a certificate of service on 8/99 2 Telephone No.: Facsimile No.: E-Mail Address: Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : : Index No. Calendar No. : anything you file after your petition showingPlaintiff(s) mailed copies and to whom they were sent. The when you JUDICIAL SUBPOENA certificate of service appears at the end of the pleading or motion and looks like the sample below. -against- : CERTIFICATE OF SERVICE : : I hereby certify that on this ______ day of ___________________, 19__, a copy of this (title of the document) , was mailed, postage prepaid, to Defendant(s) : . .(name . . . .address .of .the .attorney.or. person. to. whom. you .sent it). . . . . . and . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . (your signature THE PEOPLE OF THE STATE OF NEW YORK ) It TO is not necessary to state in the certificate of service that copies were sent to the Court or the Clerk. Do not file any motions or memoranda that are longer than fifty pages unless you have received permission from the Court. Most motions and memoranda should be much shorter than fifty pages. GREETINGS: You doWE COMMAND YOU,of exhibits that are already onbeing laid aside, you and each of you attend before not have to file copies that all business and excuses file in the same case. For example, if the , the Honorable in your case file an answer and attach as an exhibit Court motion a copy of a parole at the respondents to their County of decision, you do not located at revocation have to attach a copy of that document to any motions you file. You may insimply refer to theon thethat is day of in the file. , 20 room , copy , at o'clock in the noon, and at any recessed already or adjourned date, to testify and give evidence as a witness in this action on the part of the You must sign every pleading, motion, and memorandum that you file. You MAY NOT sign someone else’s name, nor may you file anything on behalf of someone else. Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a result of your failure to comply. Witness, Honorable Court in County, , one of the Justices of the day of , 20 (Attorney must sign above and type name below) Attorney(s) for Office and P.O. Address 8/99 3 Telephone No.: Facsimile No.: E-Mail Address: Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : : Index No. Calendar No. : FORM TO BE USED BY A PERSON FILING A PETITION FOR JUDICIAL SUBPOENA Plaintiff(s) WRIT OF HABEAS CORPUS UNDER 28 U.S.C. §2241 -against- : IN THE UNITED STATES DISTRICT COURT : FOR THE DISTRICT OF MARYLAND : Defendant(s) : ...................................................... THE PEOPLE OF THE STATE OF NEW YORK TO (Full name, date of birth, identification number and address of the petitioner) GREETINGS: v. Civil Action No. (Leave blank. aside, you in each of you WE COMMAND YOU, that all business and excuses being laidTo be filledandby Court.) attend before , the Honorable at the Court located at County of in room , on the day of , 20 , at o'clock in the noon, and at any recessed or adjourned date, to testify and give evidence as a witness in this action on the part of the Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a result of your failure to comply. (Full name and address of the respondent(s)) Witness, Honorable , one of the Justices of the PETITION FOR WRIT OF HABEAS CORPUS Court in County, day of , 20 I. Background A. Where are you detained? _____ Federal Prison (Attorney must sign above and type name below) Attorney(s) for _____ State Prison _____ Local Jail or Detention Center Office and P.O. Address _____ Mental Health Facility 8/99 Telephone No.: Facsimile No.: E-Mail Address: Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : : B. Index No. Calendar No. : _____ Other, describe ________________________________________________ JUDICIAL SUBPOENA Plaintiff(s) If you have been convicted and sentenced, provide the following information: -against- 1. : Name and location of court which imposed sentence: __________________ : : __________________________________________________________________. Defendant(s) : . . . . . . . . . . . . . . .2.. . . . . Your. criminal .case .number(s): . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ___________________________________. 3. The date you were sentenced: ____________________________________. THE PEOPLE OF THE STATE OF NEW YORK 4. The charges on which you were convicted: ________________________ TO __________________________________________________________________. C. GREETINGS: If you are awaiting trial on criminal charges, provide the following information: 1. Name and location of court excuses charges are pending: ______________ WE COMMAND YOU, that all business andin which being laid aside, you and each of you attend before , the Honorable at the Court located at County of __________________________________________________________________. in room , on the day of , 20 , at o'clock in the noon, and at any recessed or adjourned date, to testify and give evidence as a witness in this action on the part of the 2. Your criminal case number(s): ___________________________________. 3. List any hearing or trial dates which have been scheduled: ______________ Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a __________________________________________________________________. result of your failure to comply. 4. List the charges that are pending against you: ________________________ Witness, Honorable Court in County, , one of the Justices of the day of , 20 __________________________________________________________________. 5. Your attorney’s name, address and telephone number: _________________ (Attorney must sign above and type name below) __________________________________________________________________. D. Attorney(s) for If you are detained in a mental health facility, provide the following information: 1. How were you committed? Office and P.O. Address _____ By a court for evaluation. 8/99 2 Telephone No.: Facsimile No.: E-Mail Address: Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : : Index No. Calendar No. _____ By a court after being found not:criminally responsible. JUDICIAL SUBPOENA Plaintiff(s) -against- _____ Involuntary civil commitment. : : _____ Other, explain, __________________________________________ : ____________________________________________________________. Defendant(s) : ...................................................... 2. When were you committed? _____________________________________. II. Previous lawsuits THE PEOPLE OF THE STATE OF NEW YORK TO A. Have you filed other cases or motions in state or federal court dealing with the same facts as in this case? YES [ ] GREETINGS: NO [ ] B. If you answered YES, business and excuses being laid aside, you and below. WE COMMAND YOU, that alldescribe that case(s) or motion(s) in the spaces each of you attend before , the Honorable at the Court located at County of 1. Type of case or motion: in room , on the day of , 20 , at o'clock in the noon, and at any recessed or adjourned date, to testify and give evidence as a witness in this action on the part of the . 2. Parties to the other case(s): Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to the party on whose behalfPetitioner: this subpoena was issued for a maximum penalty of $50 and all damages sustained as a result of your failure to comply. Respondent(s): Witness, Honorable , one of the Justices of the 3. Court (if a federal court name the district; if a state court name the city or Court in County, day of , 20 4. county): Case No.: 5. Date filed: 6. 7. Name of judge that handled the case: Disposition (won, dismissed, still pending, on appeal): 8. Date of disposition: (Attorney must sign above and type name below) Attorney(s) for Office and P.O. Address 8/99 3 Telephone No.: Facsimile No.: E-Mail Address: Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : Index No. : III. Administrative proceedings A. : Plaintiff(s) -against- Calendar No. JUDICIAL SUBPOENA : If you are in a Division of Correction facility, did you file an administrative remedy procedure request under DCD 185-001, et seq.? : YES [ ] NO [ : ] Defendant(s) : . . . . . . . . . . . . . . .1.. . . . . If. you .answered. YES:. . . . . . . . . . . . . . . . . ... ....... .... a. What was the result? THE PEOPLE OF THE STATE OF NEW YORK TO b. Did you appeal to the Commissioner? YES [ ] GREETINGS: NO [ ] 2. If you answered NO to either of the questions above, explain why you you attend WE COMMAND YOU, that all business and excuses being laid aside, you and each ofdid not file before , the Honorable at the an administrative remedy procedure requestCourt appeal to the or an located at County of in room , on theCommissioner. day of , 20 , at o'clock in the noon, and at any recessed or adjourned date, to testify and give evidence as a witness in this action on the part of the Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a result of your failure to comply. 3. Did you file any other type of administrative complaint such as an appeal to the warden of an adjustment decision? Witness, Honorable Court in County, 4. , one of the Justices of the day of YES [ ] , 20 NO [ ] If you answered YES, explain what you filed must sign above and type name below) and what was the result. (Attorney Attorney(s) for Office and P.O. Address B. 8/99 If you are in a Division of Correction facility or Patuxent Institution, did you file a complaint with the Inmate Grievance Office? 4 Telephone No.: Facsimile No.: E-Mail Address: Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : Index No. : YES [ ] 1. : NO [ ] Plaintiff(s) -against- Calendar No. JUDICIAL SUBPOENA : If you answered YES: : a. What was the result? : . Defendant(s) : ...................................................... b. Did you appeal to the Circuit Court? YES [ ] THE PEOPLE OF THE STATE OF NEW YORK NO [ c. TO ] What was the result? . d. GREETINGS: Did you file an application for leave to appeal to the Court of Special Appeals? WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before , the Honorable at [ Court YES [ ] NOthe ] located at County of in room , on thee. day of was the result? , 20 , at o'clock in the noon, and at any recessed What or adjourned date, to testify and give evidence as a witness in this action on the part of the . C. If you are a state prisoner challenging a parole revocation decision, complete the following. Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to the party on whose behalfDate subpoena wasdecision: a maximum penalty of $50 and all damages sustained as a this of revocation issued for 1. . result of your failure to comply. 2. Did you appeal the revocation decision to the Circuit Court? Witness, Honorable Court in County, YES [ ] 3. , one of the Justices of the day of NO [ , 20 ] If you answered YES, what was the date of the Circuitabove and type name below) Court’s decision and what (Attorney must sign was the decision? Attorney(s) for . 4. Did you appeal the decision of the Circuit Court? Address Office and P.O. YES [ ] 8/99 NO [ ] 5 Telephone No.: Facsimile No.: E-Mail Address: Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : : 5. Index No. Calendar No. : If you answered YES, what was the result andJUDICIAL SUBPOENA the date of the decision? Plaintiff(s) -against- : : . : D. If you are in a Federal facility, did you attempt to resolve your complaint informally? Defendant(s) : ...................................................... YES [ ] NO [ ] 1. If you OF NEW YES: THE PEOPLE OF THE STATE answered YORK a. TO Did you file a formal complaint to the warden? YES [ ] GREETINGS: b. NO [ ] Did you appeal the warden’s decision to the Regional Director? WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before , the Honorable YES [ at the NO [ ] Court ] located at County of in room , on thec. day ofyou appeal the Regional Director’s decision to the noon, and General , 20 , at o'clock in the Did Office of at any recessed or adjourned date, to testify and give evidence as a witness in this action on the part of the Counsel? YES [ ] NO [ ] Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to the party on whose behalfd. subpoenawas the result? a maximum penalty of $50 and all damages sustained as a this What was issued for result of your failure to comply. Witness, Honorable Court in County, 2. , one of the Justices of the day of , 20 If you answered NO to any of the questions above, explain why you did not file an administrative complaint or appeal . (Attorney must sign above and type name below) Attorney(s) for E. 8/99 If you are a federal prisoner challenging a Office and P.O. Address parole revocation decision, complete the following. 6 Telephone No.: Facsimile No.: E-Mail Address: Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : Index No. : Calendar No. : JUDICIAL SUBPOENA . 1. Date of revocation decision: Plaintiff(s) 2. Did you appeal the revocation decision to the National Appeals Board? -against- : : YES [ ] NO [ ] : 3. If you answered YES, what was the date of the National Appeals Board’s Defendant(s) : . . . . . . . . . . . . . . . . . . . . . decision . . . .what . . . . the. decision. . . . . . . . . . . . and . . . . was . . . . . . . . . THE PEOPLE OF THE STATE OF NEW YORK . TO F. GREETINGS: If you are not in a Division of Correction or Federal facility, is there a grievance procedure at your institution? YES [ ] NO [ ] WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before , the Honorable If your answer is YES: at the Court located at County of in room , day of , at o'clock in the noon, and at any recessed 1.on theDid you file a grievance? , 20 or adjourned date, to testify and give evidence as a witness in this action on the part of the YES [ ] NO [ ] Your failure to comply filed a grievance whatpunishable as a contempt of court and will make you liable to 2. If you with this subpoena is was the result? the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a result of your failure to comply. Witness, Honorable 3. If you did not file a grievance explain why not? Court in County, day of , 20 , one of the Justices of the (Attorney must sign above and type name below) Attorney(s) for Office and P.O. Address 8/99 7 Telephone No.: Facsimile No.: E-Mail Address: Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : : IV. Index No. Calendar No. : Statement of claim JUDICIAL SUBPOENA Plaintiff(s) (Briefly state the facts of your case. Include dates, times, and places. Explain why you believe you -against: are improperly detained. If you are making a number of related claims, number and explain each claim in a separate paragraph.) : : Defendant(s) : ...................................................... THE PEOPLE OF THE STATE OF NEW YORK TO GREETINGS: WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before , the Honorable at the Court located at County of in room , on the day of , 20 , at o'clock in the noon, and at any recessed or adjourned date, to testify and give evidence as a witness in this action on the part of the V. Relief (State briefly what you want the Court to do for you) Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a result of your failure to comply. Witness, Honorable , one of the Justices of the I DECLARE UNDER THE PENALTIES OF PERJURY THAT THE INFORMATION ABOVE Court in County, day of , 20 IS TRUE AND CORRECT. SIGNED THIS ______ day of _______________________, ______. sign above and type name below) (Attorney must Attorney(s) for (original signature of petitioner) Office and P.O. Address 8/99 8 Telephone No.: Facsimile No.: E-Mail Address: Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : Index No. : Plaintiff(s) -against- Calendar No. : JUDICIAL SUBPOENA (address of petitioner) : : : Defendant(s) : ...................................................... THE PEOPLE OF THE STATE OF NEW YORK TO GREETINGS: WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before , the Honorable at the Court located at County of in room , on the day of , 20 , at o'clock in the noon, and at any recessed or adjourned date, to testify and give evidence as a witness in this action on the part of the Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a result of your failure to comply. Witness, Honorable Court in County, , one of the Justices of the day of , 20 (Attorney must sign above and type name below) Attorney(s) for Office and P.O. Address 8/99 9 Telephone No.: Facsimile No.: E-Mail Address: Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : : Index No. Calendar No. : FORM TO BE USED BY A PERSON SEEKING LEAVE TO PROCEED JUDICIAL SUBPOENA Plaintiff(s) IN FORMA PAUPERIS IN A HABEAS CORPUS ACTION -against- : IN THE UNITED STATES DISTRICT COURT : FOR THE DISTRICT OF MARYLAND : Defendant(s) : ...................................................... (name of petitioner) v. THE PEOPLE OF THE STATE OF NEW YORK Civil Action No. (Leave blank. To be filled in by Court.) TO (name of respondent) GREETINGS: MOTION AND that all business and excuses being laid aside, you and each WE COMMAND YOU, AFFIDAVIT TO PROCEED IN FORMA PAUPERIS of you attend before , the Honorable at the Court located at County ofI, , declare that I am the petitioner in this case. I in room , on the day of , 20 , at o'clock in the noon, and at any recessed or adjourned date, to testify and give evidence as a witness in this action on the part of the understand that the fee for filing this type of case is $5.00. Because of my poverty, I am unable to pay the filing fee and costs of this action at this time, nor am I able to give security therefor. Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to the party on whosethat I have asubpoena was issued for a maximum penalty ofin these proceedings. sustained as a I believe behalf this meritorious complaint and am entitled to relief $50 and all damages result of your failure to comply. In support of this motion, I answer the following questions: Witness, Honorable Court in County, 1. day of , one of the Justices of the , 20 Are you presently employed in an institutional job or other assignment that results in compensation of any sort, including work release? YES [ ] a. NO [ ] (Attorney must sign above and type name below) If you answered YES, list your employer or assignment and the amount of your Attorney(s) for wages. Employer/assignment: Office and P.O. Address Monthly gross wages: 8/99 Telephone No.: Facsimile No.: E-Mail Address: Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : Index No. : Monthly net wages:Plaintiff(s) b. -against- Calendar No. : JUDICIAL SUBPOENA : If you answered NO, state the date of your last employment or assignment, the name of your employer or assignment, and the amount of wages you received. : : Date: Defendant(s) : . . . . . . . . . . . . . . . . . . . . . Employer/assignment: . . . . . . . . . . . . . . . .................. Monthly gross wages: Monthly net wages: THE PEOPLE OF THE STATE OF NEW YORK 2. TO GREETINGS: Within the past twelve months have you received any income from: 1) settlements, judgments, or monetary awards from a court; 2) Social Security, public assistance, workers’ compensation or disability payments; 3) a business, profession or other form of self-employment; 4) rent, interest or dividends; 5) retirement, annuity, pension or insurance payment; 6) gifts or inheritances; 7) or any other sources? YES [ ] NO [ WE COMMAND YOU, that all business]and excuses being laid aside, you and each of you attend before , the Honorable at the Court locatedlist the amount received, date it was received, and the source. at County of If you answered YES, in room , on the day of , 20 , at o'clock in the noon, and at any recessed or adjourned date, to testify and give evidence as a witness in this action on the part of the Amount Date received Source Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a result of your failure to comply. Witness, Honorable Court in County, 3. 4. 5. , one of the Justices of the day of , 20 How much money do you have in your institutional account? How much money do you have in checking, savings or other accounts outside of the institution? (Attorney must sign above and type name below) Do you own or have any interest in any real estate, stocks, bonds, notes, automobiles, or other valuable property (not including ordinary household furnishings and clothes)? YES [ ] NO [ Attorney(s) for ] Office and P.O. Address If you answered YES, list the value and describe each item. 8/99 2 Telephone No.: Facsimile No.: E-Mail Address: Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : Index No. : Value : Description Plaintiff(s) -against- Calendar No. JUDICIAL SUBPOENA : : : Defendant(s) : ...................................................... 6. List everyone OF NEW businesses and the government) that you owe money and the THE PEOPLE OF THE STATE (includingYORK amount that you owe. TO Creditor Total debt Monthly payment GREETINGS: WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before , the Honorable at the Court located at County of in room , on the day of , 20 , at o'clock in the noon, and at any recessed or adjourned date, to testify and give evidence as a witness in this action on the part of the 7. List any other major monthly expenses that you are actually paying. Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to the party on whose behalf this subpoena was issued for a maximum penalty of $50payment damages sustained as a Description Monthly and all result of your failure to comply. Witness, Honorable Court in County, , one of the Justices of the day of , 20 (Attorney must sign above and type name below) I DECLARE UNDER THE PENALTIES OF PERJURY THAT THE INFORMATION ABOVE IS TRUE AND CORRECT. Attorney(s) for (date) 8/99 (original signature of petitioner) Office and P.O. Address 3 Telephone No.: Facsimile No.: E-Mail Address: Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com