FORM 5 STATE OF SOUTH CAROLINA ) ) IN THE COURT OF COMMON PLEAS County of __________________________ ) ) __________________________________ ) Full name and prison number (if any) of Applicant ) ) v. ) ) APPLICATION FOR ) State of South Carolina ) POST-CONVICTION RELIEF ) ) ) INSTRUCTIONS B READ CAREFULLY In order for this application to receive consideration by the Court, it shall be in writing (legibly handwritten or typewritten), signed by the applicant and verified (notarized), and it shall set forth in concise form the answers to each applicable question. If necessary, applicant may furnish his answer to a particular question on the reverse side of the page or on an additional page. Applicant shall make clear to which question any such continued answer refers. Since every application must be sworn under oath, any false statement of a material fact therein may serve as the basis of prosecution and conviction for perjury. Applicants should, therefore, exercise care to assure that all answers are true and correct. If the application is taken in forma pauperis, it shall include an affidavit (attached at the back of the form) setting forth information which establishes that applicant will be unable to pay the fees and costs of the proceedings. When the application is completed, the original shall be mailed to the Clerk of Court for the County in which the applicant was convicted. 1. Place of detention ________________________________________________________ _______________________________________________________________________ 2. Name and location of Court which imposed sentence ____________________________ _______________________________________________________________________ 3. Name(s) of co-defendant(s) (if any) 4. The indictment number or numbers (if known) upon which and the offenses for which sentence was imposed: (a) _________________________________________________________________ (b) _________________________________________________________________ 1 >>>> 2 (c) _________________________________________________________________ 5. The date upon which sentence was imposed and the terms of the sentence: (a) _________________________________________________________________ (b) _________________________________________________________________ (c) _________________________________________________________________ 6. Check whether a finding of guilty was made: (a) after a plea of guilty ________________________________________________ (b) after a plea of not guilty _____________________________________________ (c) after a plea of nolo contendere ________________________________________ 7. Did you appeal from the judgment of conviction or the imposition of sentence? _______________________________________________________________________ 8. If you answered Ayes@ to (7), list: (a) the name of each Court to which you appealed: i. _________________________________________________________________ ii. _________________________________________________________________ iii. _________________________________________________________________ (b) the result in each such Court to which you appealed: i. _________________________________________________________________ ii. _________________________________________________________________ iii. _________________________________________________________________ (c) the date of each such result: i. _________________________________________________________________ ii. _________________________________________________________________ iii. _________________________________________________________________ (d) if known, citations of any written opinion or orders entered pursuant to such results: i. _________________________________________________________________ ii. _________________________________________________________________ iii. _________________________________________________________________ 9. If you answered Ano@ to (7), state your reasons for not so appealing: (a) _________________________________________________________________ (b) _________________________________________________________________ 2 >>>> 3 (c) _________________________________________________________________ 10. State concisely the grounds on which you base your allegation that you are being held in custody unlawfully: (a) _________________________________________________________________ (b) _________________________________________________________________ (c) _________________________________________________________________ 11. State concisely and in the same order the facts which support each of the grounds set out in (10): (a) _________________________________________________________________ (b) _________________________________________________________________ (c) _________________________________________________________________ 12. Prior to this application have you filed with respect to this conviction: (a) any petition in a State Court under South Carolina Law?____________________ (b) any petition in State or Federal Courts for habeas corpus or post-convictions relief? ___________________________________________________________ (c) any petition in the United States Supreme Court for certiorari other than petitions, if any, already specified in (8)? ________________________________________ (d) any other petitions, motions or applications in this or any other Court? _________ 13. If you answered Ayes@ to any part of (12), list with respect to each petition, motion or application: (a) the specific nature thereof: i. _________________________________________________________________ ii. _________________________________________________________________ iii. _________________________________________________________________ iv. _________________________________________________________________ (b) the name and location of the Court in which each was filed: i. _________________________________________________________________ ii. _________________________________________________________________ iii. _________________________________________________________________ iv. _________________________________________________________________ 3 >>>> 4 (c) the disposition thereof: i. _________________________________________________________________ ii. _________________________________________________________________ iii. _________________________________________________________________ iv. _____________________