2002 © American LegalNet, Inc. FORM FOR USE IN APPLICATIONS FOR HABEAS CORPUS UNDER 28 U.S.C. SECTION 2241 UNITED STATES DISTRICT COURT FOR THE NORTHERN DISTRICT OF NEW YORK CASE NO. (to be supplied by the Clerk of Court) , PETITIONER (Full name -- include name under which you were convicted) v. , RESPONDENT (Name of Warden, Superintendent, Jailor, or authorized person having custody of petitioner) __________________________________________________________ NAME AND PRISON NUMBER PLACE OF CONFINEMENT (If the petitioner wishes to attack a federal judgment under which a sentence was imposed he/she should file a motion under 28 U.S.C. Section 2255, in the federal court which entered the judgment). PETITION FOR WRIT OF HABEAS CORPUS UNDER SECTION 2241 BY A PERSON IN FEDERAL CUSTODY INSTRUCTIONS--READ CAREFULLY This petition must be legibly handwritten or typewritten, signed by the petitioner 1. and subscribed to under penalty of perjury as being true and correct. Any false statement of a material fact may serve as the basis for prosecution and conviction for perjury. All questions must be answered concisely in the proper space on the form. Where more room is needed to answer any question type or use lined paper. No citation of authorities need be furnished. If briefs or arguments are submitted, 2. they should be submitted in the form of a separate memorandum. 3. Upon receipt of a fee of $5.00 your petition will be filed if it is in proper order. 2002 © American LegalNet, Inc. 4. If you do not have the necessary filing fee, you may submit an application to proceed in forma pauperis , in which event you must execute the affidavit on the last page, setting forth information establishing your inability to prepay the fees and costs or give security therefor. You must also have an authorized official at the correctional facility complete the certificate as to the amount of money and securities on deposit to your credit in any account in the institution. If your prison account exceeds $150.00, you must pay the filing fee as required by the rule of the district court. 5. Only judgments entered by one court may be challenged in a single petition. If you seek to challenge judgments entered by different courts either in the same state or different states, you must file separate petitions as to each court. 6. Your attention is directed to the fact that you must include all grounds for relief and all facts supporting such grounds for relief in the petition you file seeking relief from any judgment of conviction. 7. When the petition is fully completed, the original and two copies must be mailed to the Clerk of the United States District Court whose address is: 100 South Clinton Street, Syracuse, New York 13261. 8. Petitions which do not conform to these instructions will be returned with a notation as to the deficiency. PETITION 1. Name and location of court which entered the judgment of conviction under which you are presently confined: 2. Date of judgment of conviction: 3. Length of sentence: 4. Nature of offense or offenses for which you were convicted: Sentencing Judge: 2002 © American LegalNet, Inc. 5. Were you sentenced on one or more than one count of an indictment, or on more than one indictment, in the same court and at the same time? YES ( ) NO ( ). 6. Do you have any further sentence to serve after you complete the sentence imposed by the judgment under attack? YES ( ) NO ( ). (a) If so, give name and location of court which imposed sentence to be served in the future: (b) And give date and length of sentence to be served in the future: (c) Have you filed, or do you contemplate filing, a petition attacking the judgment which imposed the sentence to be served in the future? YES ( ) NO ( ). 7. State concisely every ground on which you claim that you are being held unlawfully. Summarize briefly the facts supporting each ground: (a) Ground one: Supporting FACTS (Tell your story briefly without citing cases or law): 2002 © American LegalNet, Inc. (b) Ground two: Supporting FACTS (Tell your story briefly without citing cases or law): (b) Ground three: Supporting FACTS (Tell your story briefly without citing cases or law): 2002 © American LegalNet, Inc. (b) Ground four: Supporting FACTS (Tell your story briefly without citing cases or law): WHEREFORE, petitioner prays that the court grant petitioner relief to which he/she may be entitled in this proceeding. I declare under penalty of perjury that the foregoing is true and correct. (Date) (Signature) (Signature of Attorney (if any)) 2002 © American LegalNet, Inc. UNITED STATES DISTRICT COURT NORTHERN DISTRICT OF NEW YORK APPLICATION TO PROCEED WITHOUT FULL PREPAYMENT OF FEES; AFFIDAVIT AND AUTHORIZATION FORM Plaintiff v. Defendant(s) CASE NUMBER: I, _____________________declare that I am the (check appropriate box) 9 petitioner/plaintiff/movant 9 other in the above-entitled proceeding; that in support of my request to proceed without prepayment of fees or costs under 28 USC. § 1915 I declare that I am unable to pay the costs of these proceedings and that I am entitled to the relief sought in the complaint / petition / motion. In support of this application, I answer the following questions under penalty of perjury: 9 Yes 1. Are you currently incarcerated?: 9 No (If “No” go to Part 2) If “Yes” state the place of your incarceration:_____________________________________________________ 9 Yes 9 Yes: 9 No 9 No 9 Yes Are you employed at the institution? 9 No Do you receive any payment from same? Notice to Inmates: The Certificate portion of this affidavit must be completed. 2. Are you currently employed?: a. If the answer is “Yes” state the amount of your take-home salary or wages and pay period and give the name and address of your employer. b. If the answer is “No” state the date of your last employment, the amount of your take home salary or wages and the name and address of your last employer. 3. In the past twelve months have you received any money from any of the following sources? a. Business, profession or other self employment b. Rent payments, interest or dividends c. Pensions, annuities or life insurance payments 9 Yes 9 Yes 9 Yes 9 No 9 No 9 No FORM F. 1 2002 © American LegalNet, Inc. 9 Yes 9 Yes 9 Yes d. Disability or workers compensation payments e. Gifts or inheritances f. Any other sources 9 No 9 No 9 No If the answer to any of the above is “Yes” describe each source of money and state the amount received and what you expect you will continue to receive. 4. Do you have any cash, checking or savings accounts? 9 Yes 9 No If “Yes” state the total amount. ________________ 5. Do you own any real estate, stocks, bonds, securities, other financial instruments, 9 Yes automobiles or any other assets? 9 No If “Yes” describe the property and state its value (attach additional sheets as necessary): 6. List the persons who are dependent on you for support, state your relationship to each person and indicate how much you contribute to their support. I declare under penalty of perjury that the above information is true and correct. ___________________________________________________________________________ DATE SIGNATURE OF APPLICANT CERTIFICATE (To be completed by appropriate official at the institution of incarceration) I certify that the applicant named herein has the sum of $______________ on account to his/her credit at (name of institution) _______________________________ . I further certify that the applicant has the following securities to his/her credit: ___________________________. I further certify that during the past six months the applicant’s average balance was $____________________. ___________________ DATE ______________________________________ SIGNATURE OF AUTHORIZED OFFICER FORM F. 2 2002 © American LegalNet, Inc. INMATE AUTHORIZATION I, , authorize the agency holding me in custody to send to the Clerk of the United States District Court for the Northern District of New York ("Clerk"), at his request, a certified copy of the statements, for the past six months, of my trust fund account (or institutional equivalent) at the institution where I am currently incarcerated. If I have not been incarcerated at my current place of confinement for at least six (6) months, I authorize such agency to provide said Clerk, at his request, with copies of such account statements from the institution(s) in which I had previously been incarcerated. I further request and authorize the agency holding me in custody to calculate, encumber and/or disburse funds from my trust fund account (or institutional equivalent) in the amounts specified by 28 U.S.C. § 1915(b). This authorization is furnished in connection with the commencement of the civil action submitted herewith (or noted below), and I understand that the total filing fee which I am obligated to pay is $150.00. I also understand that this fee will be debited from my account regardless of the outcome of my lawsuit. This authorization shall apply to any other agency into whose custody I may be transferred. º Signature: i NOTE: You must sign your name on the above line. i 444444444444444444444444444444444444444444444444444444444444444444444444444444444444444444444 Name and DIN Number: Civil action number: Short name of case: FORM G 2002 © American LegalNet, Inc.