NAME:___________________________________ Prison Number:_____________________________ Place of Confinement:________________________ _____________________________________________________________________________________ UNITED STATES DISTRICT COURT NORTHERN DISTRICT OF NEW YORK Petitioner v. Respondent(s) Civil Case Number___________________________ REQUEST BY PRISONER UNDER NEW YORK DEATH JUDGMENT FOR APPOINTMENT OF COUNSEL PURSUANT TO 18 U.S.C. SECTION 3006A I,_____________________________________, request that the Court appoint an attorney to represent me in death penalty habeas corpus litigation to be initiated in the federal courts on my behalf. In support of this request, I hereby declare: 1. I was sentenced to death in the _____________________________County Court, State of New York, on____________________________________. I am incarcerated at_____________________________ _____________________________Correctional Facility located in ______________________________, New York. 2. My death sentence was affirmed by the New York State Court of Appeals on____________________ ___________________________. 3. I intend to file a petition for writ of habeas corpus in this Court, alleging federal constitutional errors which entitle me to relief from the judgment of death. I need the assistance of counsel in preparing and litigating the petition. 4. The attorney who represented me in the most recent state court proceedings related to my death sentence was ____________________________________. He/she has informed me that he/she is not available to represent me in federal habeas corpus proceedings. 2002 © American LegalNet, Inc. 5. I cannot afford to retain an attorney to represent me in these proceedings. I have following assets (include any income, cash and property): ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ and the following debts: ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ I DECLARE UNDER PENALTY OF PERJURY THAT THE ABOVE STATEMENTS ARE TRUE AND CORRECT. Date:_____________________________ ___________________________________________ Signature of Petitioner 2002 © American LegalNet, Inc.