UNITED STATES DISTRICT COURT
NORTHERN DISTRICT OF ALABAMA
INSTRUCTIONS FOR FILING A PETITION
FOR WRIT OF HABEAS CORPUS PETITION UNDER 28 U.S.C. § 2241
Who Should Use This Form. You should use this form if
$ You are a federal prisoner and you wish to challenge the way your sentence is being carried out
(for example, you claim that the Bureau of Prisons miscalculated your sentence or failed to
properly award good time credits);
$ You are in federal or state custody because of something other than a judgment of conviction
(for example, you are in pretrial detention or are awaiting extradition); or
$ You are alleging that you are illegally detained in immigration custody.
Who Should Not Use This Form. You should not use this form if
$ You are challenging the validity of a federal judgment of conviction and sentence (these
challenges are generally raised in a motion under 28 U.S.C. § 2255);
$ You are challenging the validity of a state judgment of conviction and sentence (these challenges
are generally raised in a petition under 28 U.S.C. § 2254); or
$ You are challenging a final order of removal in an immigration case (these challenges are
generally raised in a petition for review directly with a United States Court of Appeals).
The petition must be legibly handwritten or typewritten and signed by the petitioner under penalty of perjury. If
you make a false statement of material fact, you may be prosecuted for perjury.
All questions must be answered concisely in the proper space on the form. If needed, you may attach additional
pages. If you attach additional pages, number the pages and identify which section of the petition is being
continued. Do NOT write on the back of any page.
In order for your petition to be filed, it must be accompanied by the $5.00 filing fee. If you are unable to pay the
filing fee, you may petition the court to proceed as an indigent party. An Application to Proceed In Forma
Pauperis is included with this petition.
No more than one petitioner may be named in a petition. Each petitioner must file a separate petition and
Application to Proceed In Forma Pauperis or filing fee. Your petition may be brought in this court only if you are
incarcerated in one of the following counties geographically located in the United States District Court for the
Northern District of Alabama: BIBB, BLOUNT, CALHOUN, CHEROKEE, CLAY, CLEBURNE, COLBERT,
CULLMAN, DEKALB, ETOWAH, FAYETTE, FRANKLIN, GREENE, JACKSON, JEFFERSON, LAMAR,
LAUDERDALE, LAWRENCE, LIMESTONE, MADISON, MARION, MARSHALL, MORGAN, PICKENS,
SHELBY, ST. CLAIR, SUMTER, TALLADEGA, TUSCALOOSA, WALKER, or WINSTON.
You must include in this petition all grounds for relief and all facts supporting such grounds for relief. If you fail
to do so, you may be barred from presenting additional grounds at a later date.
You must immediately notify the court in writing of any change of address. If you do not, the court may dismiss
your case.
Mail the original petition and the filing fee of $5.00 or an Application to Proceed In Forma Pauperis to the
following address: Clerk’s Office, United States District Court, Northern District of Alabama, Room 140, Hugo
L. Black U.S. Courthouse, 1729 5th Avenue North, Birmingham, AL 35203-2195 or Clerk’s Office, United States
District Court, Northern District of Alabama, 101 Holmes Avenue, Huntsville, AL 35801.
AO 242 (Rev. 10/16) Petition for a Writ of Habeas Corpus Under 28 U.S.C. § 2241
UNITED STATES DISTRICT COURT
NORTHERN DISTRICT OF ALABAMA
)
)
___________________________________________________ )
Petitioner )
(Full name) )
) Civil Action No. ___________________
) (to be filled in by the
-v- ) Clerk’s Office)
)
)
____________________________________________________ )
Respondent )
(Name of warden or authorized person having custody of petitioner.) )
PETITION FOR A WRIT OF HABEAS CORPUS UNDER 28 U.S.C. § 2241
Personal Information
1. (a) Your full name:
(b) Other names you have used:
2. Place of confinement:
(a) Name of Institution:
(b) Address:
(c) Your prisoner identification number:
3. Are you currently being held on orders by:
☐ Federal authorities ☐ State authorities ☐ Other – explain:
4. Are you currently:
☐ A pretrial detainee (waiting for trial on criminal charges)
☐ Serving a sentence (incarceration, parole, probation, etc.) after having been convicted of a crime
If you are currently serving a sentence, provide:
(a) Name and location of court that sentenced you:
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(b) Docket number of criminal case:
(c) Date of sentencing:
☐ Being held on an immigration charge
☐ Other (explain)
5. What are you challenging in this petition:
☐ How your sentence is being carried out, calculated, or credited by prison or parole authorities (for
example, revocation or calculation of good time credits)
☐ Pretrial detention
☐ Immigration detention
☐ Detainer
☐ The validity of your conviction or sentence as imposed (for example, sentence beyond the
statutory maximum or improperly calculated under the sentencing guidelines)
☐ Disciplinary proceedings
☐ Other (explain)
6. Provide more information about the decision or action you are challenging:
(a) Name and location of the agency or court:
(b) Docket number, case number, or opinion number:
(c) Decision or action you are challenging (for disciplinary proceedings, specify the penalties
imposed):
(d) Date of the decision or action:
Your Earlier Challenges of the Decision or Action
7. First Appeal
Did you appeal the decision, file a grievance, or seek an administrative remedy?
☐ Yes ☐ No
(a) If “Yes,” provide:
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(1) Name of authority, agency, or court:
(2) Date of filing:
(3) Docket number, case number, or opinion number:
(4) Result:
(5) Date of result:
(6) Issues raised:
(b) If you answered “No,” explain why you did not appeal:
8. Second Appeal
After the first appeal, did you file a second appeal to a higher authority, agency, or court:
☐ Yes ☐ No
(a) If “Yes,” provide:
(1) Name of authority, agency, or court:
(2) Date of filing:
(3) Docket number, case number, or opinion number:
(4) Result:
(5) Date of result:
(6) Issues raised:
(b) If you answered “No,” explain why you did not file a second appeal:
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9. Third Appeal
After the second appeal, did you file a third appeal to a higher authority, agency, or court:
☐ Yes ☐ No
(a) If “Yes,” provide:
(1) Name of authority, agency, or court:
(2) Date of filing:
(3) Docket number, case number, or opinion number:
(4) Result:
(5) Date of result:
(6) Issues raised:
(b) If you answered “No,” explain why you did not file a third appeal:
10. Motion Under 28 U.S.C. § 2255
In this petition, are you challenging the validity of your conviction or sentence as imposed?
☐ Yes ☐ No
If “Yes,” answer the following:
(a) Have you already filed a motion under 28 U.S.C. § 2255 that challenged this conviction or
sentence? ☐ Yes ☐ No
If “Yes,” provide:
(1) Name of court:
(2) Case number:
(3) Date of filing:
(4) Result:
(5) Date of result:
(6) Issues raised:
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(b) Have you ever filed a motion in a United States Court of Appeals under 28 U.S.C. §
2244(b)(3)(A), seeking permission to file a second or successive Section 2255 motion to
challenge this conviction or sentence?
(c) Explain why the remedy under 28 U.S.C. § 2255 is inadequate or ineffective to challenge your
conviction or sentence:
11. Appeals of immigration proceedings
Does this case concern immigration proceedings?
☐ Yes ☐ No
If “Yes,” provide:
(a) Date you were taken into immigration custody:
(b) Date of the removal or reinstatement order:
(c) Did you file an appeal with the Board of Immigration Appeals?
☐ Yes ☐ No
If “Yes,” provide:
(1) Date of filing:
(2) Case number:
(3) Result:
(4) Date of result:
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(5) Issues raised:
(d) Did you appeal the decision to the United States Court of Appeals?
☐ Yes ☐ No
If “Yes,” provide:
(1) Name of court:
(2) Date of filing:
(3) Case number:
(4) Result:
(5) Date of result:
(6) Issues raised:
12. Other appeals
Other than the appeals you listed above, have you filed any other petition, application, or motion about
the issues raised in this petition?
☐ Yes ☐ No
If “Yes,” provide:
(a) Kind of petition, motion, or application:
(b) Name of authority, agency, or court:
(c) Date of filing:
(d) Docket number, case number, or opinion number:
(e) Result:
(f) Date of result:
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(g) Issues raised:
Grounds for Your Challenge in This Petition
13. State every ground (reason) that supports your claim that you are being held in violation of the
Constitution, laws, or treaties of the United States. Attach additional pages if you have more than four
grounds. State the facts supporting each ground.
GROUND ONE:
(a) Supporting facts (Be brief. Do not cite cases or law.):
(b) Did you present Ground One in all appeals that were available to you?
☐ Yes ☐ No
GROUND TWO:
(a) Supporting facts (Be brief. Do not cite cases or law.):
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(b) Did you present Ground Two in all appeals that were available to you?
☐ Yes ☐ No
GROUND THREE:
(a) Supporting facts (Be brief. Do not cite cases or law.):
(b) Did you present Ground Three in all appeals that were available to you?
☐ Yes ☐ No
GROUND FOUR:
(a) Supporting facts (Be brief. Do not cite cases or law.):
(b) Did you present Ground Four in all appeals that were available to you?
☐ Yes ☐ No
14. If there are any grounds that you did not present in all appeals that were available to you, explain why you
did not:
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Request for Relief
15. State exactly what you want the court to do:
Declaration Under Penalty of Perjury
If you are incarcerated, on what date did you place this petition in the prison mail system:
I declare under penalty of perjury that I am the petitioner, I have read this petition or had it read to me, and the
information in this petition is true and correct. I understand that a false statement of a material fact may serve as
the basis for prosecution for perjury.
Date:
Signature of Petitioner
Signature of Attorney, if any
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FOR USE BY INCARCERATED PERSONS
IN THE UNITED STATES DISTRICT COURT
FOR THE NORTHERN DISTRICT OF ALABAMA
APPLICATION TO PROCEED IN FORMA PAUPERIS
Declaring that the personal and financial information I have given below is true and correct, I apply to
this court for authority to proceed with this case without prepayment of fees, costs, or security.
1. Your full name:
Present mailing address:
2. Are you presently employed? ☐ Yes ☐ No
If the answer is “Yes,” give the name and address of your employer and the amount of your usual
monthly salary or wages.
Name and Address:
Amount of earnings: $ per (specify pay period)
If the answer is “No,” give the name and address of your last employer, when you last worked, and the
amount of the monthly salary or wages you were receiving.
Name and Address:
Date last worked:
Amount of earnings: $ per (specify pay period)
3. Have you received within the past twelve months any money from any of the following sources?
(a) Business, profession, or any form of self-employment? G Yes G No
(b) Interest, dividends, rents or investment income of any kind? G Yes G No
(c) Pensions, annuities, or life insurance payments? G Yes G No
(d) Gifts or inheritances? G Yes G No
(e) Any other sources? G Yes G No
If the answer to any of the above is “Yes,” describe each source of money and state the amount received
from each during the past twelve months:
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4. Do you own cash, or do you have any money in any checking or saving accounts, including your prison
or jail account? ☐ Yes ☐ No
If the answer is “Yes,” state the total amount: $
5. Do you own any real estate, stocks, bonds, notes, automobiles, boats, or other valuable property
(excluding ordinary household items and clothing)? ☐ Yes ☐ No
If the answer is “Yes,” describe the property and state its approximate value:
6. List the persons who are dependent upon you for support, stating your relationship to them and how
much you contribute toward their support:
I declare (or certify, verify, or state) under penalty of perjury that the foregoing is true and correct.
Dated:
SIGNATURE OF PETITIONER
ADDRESS
PRISONER NUMBER
IMPORTANT NOTICE
Your application to proceed in forma pauperis is NOT COMPLETE and WILL NOT BE CONSIDERED
by the court unless the page entitled “INFORMATION REGARDING PRISONER ACCOUNTS” is
properly completed and certified.
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INFORMATION REGARDING PRISONER ACCOUNTS
The Prison Litigation Reform Act, Pub. L. No. 104-134, § 804, requires a prisoner seeking to proceed in
forma pauperis to submit information regarding his prison or jail trust account for the six (6) months preceding
the filing of the complaint. This information must be obtained from the appropriate official of each prison or
institution at which the prisoner is or was confined within the past six (6) months. This information must be
certified by prison or jail personnel and must include both the total deposits made to the prisoner’s account each
and every month for the preceding six (6) months and the average monthly balance in the account each and every
month during the preceding six (6) months. Information for six (6) full months must be provided.
CERTIFICATION
I hereby certify that prisoner has been incarcerated
in this institution since , , and that the prisoner has the sum of
$ in his/her prison or jail trust account on this the day of . I further
certify that the information provided below is true and correct.
Month/Year Total Deposits Received Average Account Balance
Month 1 ______________ $____________________ $______________________
Month 2 ______________ $____________________ $______________________
Month 3 ______________ $____________________ $______________________
Month 4 ______________ $____________________ $______________________
Month 5 ______________ $____________________ $______________________
Month 6 ______________ $____________________ $______________________
Current month ______________ $____________________ $______________________
(if less than full month)
Dated: _______________________ _____________________________________________
Signature of Authorized Officer of Institution
_____________________________________________
Name of Institution
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