UNITED STATES COURT OF APPEALS for the SECOND CIRCUIT CERTIFICATE OF DEATH PENALTY CASE ________________________________________ DISTRICT COURT U.S.D.C. DOCKET NUMBER LOCATION (CITY) ____________________________________ DATE PETITION FILED -------------------------------------------------------[CASE CAPTION], _______________ Fee Status Petitioner, -v.- Paid _________ Respondent. -------------------------------------------------------COUNSEL FOR PETITIONER (Name, Address & Telephone Number) IFP ________ IFP Pending ________________ COUNSEL FOR RESPONDENT (Name, Address & Telephone Number) PETITIONER’S NAME, PRISONER I.D. #, INSTITUTION OF INCARCERATION, ADDRESS &TELEPHONE NUMBER THIS CASES ARISES FROM: State Court Judgment _____. Federal Court Judgment _________. Complete each of the following statements applicable to this case: 1. EXECUTION HAS BEEN SCHEDULED FOR_______________________________ (Date) 2. A verdict recommending a sentence of death was rendered on __________________ (Date) EXPLANATION OF EMERGENCY NATURE OF PROCEEDINGS (attach pages, as necessary). HAS PETITIONER PREVIOUSLY FILED CASES IN FEDERAL COURT? ______ YES (If yes, give the Court, caption, docket number, filing date, disposition, and disposition date). ______ NO DOES PETITIONER HAVE CASES PENDING IN OTHER COURTS? (If yes, give the Court, caption, docket number, filing date, and status..) ______ NO ______ YES I HEREBY CERTIFY UNDER PENALTY OF PERJURY THAT THE FOREGOING IS TRUE AND CORRECT. ____________________________________________________ Signature ____________________________________________________ Type or Print Name NOTE: THE COURT OF APPEALS PERIODICALLY WILL REQUEST CASE STATUS REPORTS. PARTIES ARE UNDER A CONTINUING AFFIRMATIVE OBLIGATION TO IMMEDIATELY NOTIFY THE UNITED STATES COURT OF APPEALS FOR THE SECOND CIRCUIT OF ANY CHANGES OR ADDITIONS TO THE INFORMATION CONTAINED ON THIS FORM. American LegalNet, Inc. www.USCourtForms.com