CERTIFICATE OF DEATH PENALTY CASE U.S. COURT OF APPEALS, THIRD CIRCUIT United States District Court DISTRICT LOCATION DOCKET NUMBER CASE CAPTION: , Petitioner v. , Respondent DATE PETITION FILED IN DISTRICT COURT Petitioner FEE STATUS: PAID IFP IFP PENDING REV. 2/99 -1American LegalNet, Inc. www.USCourtForms.com COUNSEL FOR PETITIONER Name: COUNSEL FOR RESPONDENT Name: Office Address: Office Address: Office Telephone: ( Facsimile Number: ( E-Mail Address: ( Home Address: ) ) ) Office Telephone: ( Facsimile Number: ( E-Mail Address: ( Home Address: ) ) ) Home Telephone: ( ) Home Telephone: ( ) REV. 2/99 -2American LegalNet, Inc. www.USCourtForms.com INSTITUTION OF INCARCERATION: EXECUTION DATE (IF APPLICABLE): EXPLANATION OF EMERGENCY NATURE OF PROCEEDINGS (attach another page if necessary) REV. 2/99 -3American LegalNet, Inc. www.USCourtForms.com HAS PETITIONER PREVIOUSLY FILED CASES IN FEDERAL COURT? NO YES (give caption, number, filing date, disposition, disposition date) DOES PETITIONER HAVE CASES PENDING IN OTHER COURTS? NO YES (give court, caption, number, filing date and status) REV. 2/99 -4American LegalNet, Inc. www.USCourtForms.com I HEREBY CERTIFY UNDER PENALTY OR PERJURY THAT THE PETITIONER IS PRESENTLY UNDER A SENTENCE OF DEATH AND THAT THE INFORMATION PROVIDED ON THIS FORM IS CURRENTLY ACCURATE AND CORRECT. SIGNATURE DATE NOTE: The Court of Appeals periodically will request case status reports. Petitioner is under a continuing affirmative obligation to immediately notify the Third Circuit of any changes or additions to the information contained on this form. REV. 2/99 -5American LegalNet, Inc. www.USCourtForms.com