Rev. 03/06 WDNY PETITION FOR WRIT OF HABEAS CORPUS UNDER 28 U.S.C. § 2241 BY A PERSON IN CUSTODY A petition under 28 U.S.C. § 2241 is generally intended to be used with respect to incarceration pursuant to such determinations as INS decisions, mental health commitments, lost good time credits claims, and other state or federal decisions (other than state or federal criminal convictions) by which the petitioner is held in custody. If petitioner wishes to attack a federal court judgment under which a sentence was imposed, petitioner should file a motion under 28 U.S.C. § 2255 in the federal court which entered the judgment. If petitioner wishes to attack a state court judgment under which a sentence was imposed, petitioner should file a petition under 28 U.S.C. § 2254 in the federal court which serves the county where the judgment was entered. Check the Western District’s web site at www.nywd.uscourts.gov for copies of many of the Court’s forms and other useful information. M aterial filed in this Court is now available via the INTERNET. See Pro Se Privacy Notice for further information. INSTRUCTIONS - READ CAREFULLY 1. This petition must be legibly handwritten or typewritten, signed by the petitioner 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. 2. No citation of authorities need be furnished. If briefs or arguments are submitted, they should be submitted in the form of a separate memorandum. 3. Upon receipt of a fee of $5.00, the petition will be filed if it is in proper order. If you do not have the necessary filing fee, you may request permission to proceed in forma pauperis by completing the Court's form motion to proceed in forma pauperis. If you are a prisoner who wishes to proceed in forma pauperis, you must have an authorized official at your correctional facility complete the certificate as to the amount of money and securities on deposit to your credit in your inmate account. 4. You must include all grounds for relief and all facts supporting such grounds for relief in the petition you file. You may not be permitted the opportunity to raise any claim in a second or successive habeas corpus application that was not presented in the original habeas corpus application. See 28 U.S.C. § 2244(b). 5. A one-year statute of limitations may apply to your application for a writ of habeas corpus; the limitations period runs from the latest of several different points in time, so you must check the statute to see which date may apply to your petition. See 28 U.S.C. 2244(d)(1). You are also subject to a requirement that you must exhaust your administrative remedies before coming to federal court. See Carmona v. United States Bureau of Prisons, 243 F.3d 629 (2d Cir. 2001). 6. When the petition is fully completed, the original and two copies must be mailed to the Clerk of the United States District Court at either of the following addresses: 304 U.S. Courthouse 68 Court Street Buffalo, New York 14202 (716) 551-4211 or (716) 551-5759 7. 2120 U.S. Courthouse 100 State Street Rochester, New York 14614 (585) 263-6263 Petitions which are insufficient will be returned with a statement of the deficiency. American LegalNet, Inc. www.USCourtForms.com Revised 05/01 WDNY UNITED STATES DISTRICT COURT WESTERN DISTRICT OF NEW YORK , (Full name under which you were convicted) v. Petitioner, , (Name of warden, superintendent, jailor or authorized person having custody of petitioner) Civil No.: ___________________________ Respondent. PETITION FOR WRIT OF HABEAS CORPUS UNDER 28 U.S.C. § 2241 BY A PERSON IN CUSTODY Petitioner’s Name (and Prisoner Number, if applicable): Petitioner's Place of Confinement: 1. Provide the following information regarding the determination which you are challenging in this petition. (If you wish to challenge more than one determination, you should file a separate petition for each determination.) * Type of determination: * Who made the determination: * Where was the determination made: * When was the determination made: * Did you appeal the determination?: Yes No * If you did appeal: * To whom did you appeal: * When was the appeal decided: * What was the result of the appeal: * If you did not appeal, state why you did not: American LegalNet, Inc. www.USCourtForms.com 2. 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): (b) Ground two: Supporting facts (tell your story briefly without citing cases or law): (c) Ground three: Supporting facts (tell your story briefly without citing cases or law): (d) Ground four: Supporting facts (tell your story briefly without citing cases or law): 3. Have you filed any other habeas corpus applications with respect to this incarceration? YES NO If the answer is YES, please answer the following questions: Approximate date of filing: Court where petition filed: American LegalNet, Inc. www.USCourtForms.com Docket number of proceeding: Name of judge assigned to proceeding: Disposition: WHEREFORE, the petitioner prays that the Court grant petitioner the relief to which he or she may be entitled in this proceeding. (You may also list any specific relief you wish to obtain.) I declare under penalty of perjury that the foregoing is true and correct. Executed on: (DATE) (SIGNATURE OF PETITIONER) (SIGNATURE OF ATTORNEY (IF ANY)) American LegalNet, Inc. www.USCourtForms.com