FORM TO BE USED BY A FEDERAL PRISONER IN FILING A PETITION FOR

WRITOF HABEAS CORPUS PURSUANT TO 28 U.S.C. SECTION 2241

UNITED STATES DISTRICT COURT

[ ] DISTRICT OF [ ]

[ ] DIVISION

NO.__________________________

(leave this space blank)

_______________________________________

(Enter full name of petitioner)

Inmate Number_____________________

v.

_______________________________________

_________________________________

(Enter full name of respondent)

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1. Place of detention_______________________________________________________

2. Name and location of court which imposed sentence____________________________

________________________________________________________________________

3. List the indictment number(s)(if known) upon which sentence was imposed and the

offense(s) for which sentence was imposed._____________________________________

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

4. Give the date upon which sentence was imposed and the terms of the sentence_______

________________________________________________________________________________________________________________________________________________

5. Check whether a finding of guilty was made

□ After a plea of guilty

□ After a plea of not guilty

□ After a plea of nolo contenders

6. If you were found guilty after a plea of not guilty, check whether that finding was made by

□ a jury

□ a judge without a jury

7. Did you appeal from the judgment of conviction or the imposition of the sentence?

□ yes □ no

8. If you answered “yes” to #7, list:

(a) the name of each court to which you appealed:

(1)____________________________________________________________

(2)____________________________________________________________

(3)____________________________________________________________

(b) the result in each court to which you appealed, and the date of each such result:

(1)____________________________________________________________

(2)____________________________________________________________

(3)____________________________________________________________

(c) if known, the citations of any written opinion(s) or order(s) entered pursuant to

such results:

(1)____________________________________________________________

(2)____________________________________________________________

(3)____________________________________________________________

9. State concisely the grounds on which you base your allegations that you are being

held in custody unlawfully.__________________________________________________

[ ]

10. State concisely and in the same order the facts which support each of the grounds set

out in #9.

[ ]

11. Have you previously filed petitions for habeas corpus, motions under 28 U.S.C. § 2255, or any other applications, petitions or motions with respect to this conviction?

□ yes □ no

12. If you answered “yes” to #11, list each petition, motion or application.

(a) The specific nature thereof:

(1)___________________________________________________________

(2)___________________________________________________________

(3)___________________________________________________________

(b) The name and location of the court in which each was filled:

(1)____________________________________________________________

(2)____________________________________________________________

(3)____________________________________________________________

(c) The disposition and date of each such disposition:

(1)____________________________________________________________

(2)____________________________________________________________

(3)____________________________________________________________

(d) The citations, if known, of any written opinion(s) or order(s) entered pursuant

to each such disposition:

(1)____________________________________________________________

(2)____________________________________________________________

(3)____________________________________________________________

13. If you did not file a motion under 28 U.S.C. § 2255, or if you filed such a motion and

it was denied, state why your remedy by way of such motion is inadequate or ineffective

to test the legality of your detention:

[ ]

14. Has any ground set forth in #9 been previously presented to this court or any other

federal court by way of application for habeas corpus, motion under 28 U.S.C. § 2255, or

any other petition, motion or application?

□ yes □ no

15. If you answered “yes” to #14, identify:

(a) which grounds have been previously presented:

(1)___________________________________________________________

(2)___________________________________________________________

(3)___________________________________________________________

(b) The proceeding in which each ground was raised::

(1)____________________________________________________________

(2)____________________________________________________________

(3)____________________________________________________________

16. Were you represented by an attorney at any time during the course of

(a) your arraignment and plea? □ yes □ no

(b) your trial, if any? □ yes □ no

(c) your sentence? □ yes □ no

(d) your appeal, if any, from the judgment or conviction or the imposition of sentence? □ yes □ no

(e) your preparation, presentation or consideration of any petitions, motions or applications with respect to this conviction which you filed?

□ yes □ no

17. If you answered “yes” to one or more parts of #16, list:

(a) the name and address of each attorney who represented you:

(1)___________________________________________________

(2)___________________________________________________

(3)___________________________________________________

(b) the proceedings at which each attorney represented you:

1)___________________________________________________

(2)__________________________________________________

(3)___________________________________________________

Signed this __________day of __________________2004.

_______________________________________________

Signature of Petitioner

I declare under penalty of perjury that the foregoing is true and correct.

__________________ __________________________________________

Date Signature of Petitioner