(a) Generally.
(1) In proceedings upon which no indictment is necessary, see Fed. R. Crim.
P. 7(a)(2), deadlines in these Local Rules that commence with arraignment on
an indictment instead commence with the entry of a not guilty plea on the
trial docket. See Fed. R. Crim. P. 58(b)(1).
(2) Except as provided in paragraph (a)(3), the Defendant in an action on an
infraction, as defined in 18 U.S.C. § 19, and listed specifically in a schedule
published by order of the Court pursuant to this Rule, may pay the collateral
fixed on the citation or complaint, if any, in lieu of appearance, and by doing
so authorizes the termination of proceedings and a default judgment in the
amount of the sum fixed, pursuant to Fed. R. Crim. P. 58(d). The voluntary
forfeiture of collateral under this Rule must be treated as a finding of guilt on
the infraction charged in the citation or complaint. Government counsel and
the Clerk then may execute such judgment without further notice to the
Defendant. If a person charged with an infraction under this Rule fails to
post and forfeit collateral, any punishment authorized by law may be imposed
upon a finding of guilt.
(3) This rule does not preclude the arrest or detention of any person accused
of an infraction, as defined by 18 U.S.C. § 19, or requiring the person accused
to appear in person before a Judge, to the extent allowed by law.
(b) Trial of Misdemeanors.
(1) Generally, all misdemeanor cases are randomly assigned to the
Magistrate Judges in this District, who are authorized to conduct any or all
proceedings in such matters. All petty offense cases on the District’s docket
for a particular month are assigned to the Magistrate Judge who is serving on
criminal duty for that month. If proceedings in a petty offense case continue
past that duty month, further proceedings on the case are presided over by
the duty Magistrate Judge for the month in which the proceedings continue,
unless otherwise ordered by the Magistrate Judge who originally presided
over the matter.
(2) In all such cases in which the consent of the Defendant is required, the
Magistrate Judge must explain to Defendant that the person has a right to
trial, judgment, and sentencing by a District Judge, and that the person may
have a right to trial by jury before a District Judge or Magistrate Judge. The
Magistrate Judge must not try the case unless the Defendant consents to be
tried before the Magistrate Judge, specifically waiving a trial, judgment, and
sentencing by a District Judge. If the Defendant elects to be tried before a
District Judge, the Magistrate Judge must return the case to the Clerk, who
must randomly reassign the case to a District Judge.
PART D. APPENDIX OF FORMS
COURT FORMS
United States District Court
Southern District of Alabama
CIVIL
IN THE UNITED STATES DISTRICT COURT
FOR THE SOUTHERN DISTRICT OF ALABAMA
:
Plaintiff, :
vs. : Civil Action No.
:
:
Defendant(s) :
COMPLAINT
1. Plaintiff resides at
2. Name(s) of defendant(s)
3. Location of principal office(s) of the named defendant(s)
4. Nature of business of defendant(s)
5. Approximate number of individuals employed by defendant(s)
6. The acts complained of in this suit concern:
(A) Failure to employ me.
(B) Termination of my employment.
(C) Failure to promote me.
(D) Other acts as specified below: ________________________________________
7. Plaintiff is:
(A) Presently employed by the defendant.
(B) Not presently employed by the defendant.
The dates of employment were _______________________________________
(1) Plaintiff was discharged.
(2) Plaintiff was laid off.
(3) Plaintiff left the job voluntarily.
8. Defendant(s) discriminated against me on account of my:
(A) Race Sex
Color National Origin
Religion
Therefore, I am bringing this action for employment discrimination pursuant to Title VII
of the Civil Rights Act of 1964, specifically, 42 U.S.C. § 2000e-5.
(B) Physical disability
Mental disability
Therefore, I am bringing this action pursuant to the American with Disabilities Act,
specifically, 42 U.S.C. § 12117.
(C) Age
Therefore, I am bringing this action pursuant to the Age Discrimination in Employment
Act of 1967, specifically, 29 U.S.C. § 626.
9. The name(s), race, sex, and the position or title of the individual(s) who allegedly
discriminated against me during the period of my employment with the defendant company is
(are) _________________________________________________________________________
10. The alleged discrimination occurred on or about
11. The nature of my complaint, i.e., the manner in which the individual(s) named above
discriminated against me in terms of the conditions of my employment, is as follows: ________
12. The alleged illegal activity took place at
13. I filed charges with the Equal Employment Opportunity Commission regarding alleged
discriminatory conduct by defendant(s) on or about
I have attached a copy of the Notice-of-Right-to-Sue letter issued by the Equal Employment
Opportunity Commission. This letter was received by me on
14. I seek the following relief:
(A) Recovery of back pay.
(B) Reinstatement to my former job, and any other relief as may be appropriate,
including injunctive orders, damages, costs and attorney’s fees.
Date:
Signature of Plaintiff
Address of Plaintiff
( )
Telephone Number of Plaintiff
✎AO 85 (Local Rev. 8/06) Notice, Consent, and Order of Reference — Exercise of Jurisdiction by a United States Magistrate Judge
UNITED STATES DISTRICT COURT
District of
NOTICE, CONSENT, AND ORDER OF REFERENCE —
EXERCISE OF JURISDICTION BY A UNITED STATES
Plaintiff MAGISTRATE JUDGE
V.
Case Number:
Defendant
NOTICE OF AVAILABILITY OF A UNITED STATES MAGISTRATE JUDGE
TO EXERCISE JURISDICTION
In accordance with the provisions of 28 U.S.C. §636(c), and Fed.R.Civ.P. 73, you are notified that a United States
magistrate judge of this district court is available to conduct any or all proceedings in this case including a jury or nonjury trial,
and to order the entry of a final judgment. Exercise of this jurisdiction by a magistrate judge is, however, permitted only if all
parties voluntarily consent.
You may, without adverse substantive consequences, withhold your consent, but this will prevent the court’s jurisdiction
from being exercised by a magistrate judge. If any party withholds consent, the identity of the parties consenting or withholding
consent will not be communicated to any magistrate judge or to the district judge to whom the case has been assigned.
An appeal from a judgment entered by a magistrate judge shall be taken directly to the United States court of appeals for
this judicial circuit in the same manner as an appeal from any other judgment of this district court.
CONSENT TO THE EXERCISE OF JURISDICTION BY A UNITED STATES MAGISTRATE JUDGE
In accordance with provisions of 28 U.S.C. §636(c) and Fed.R.Civ.P. 73, the parties in this case consent to have a United
States magistrate judge conduct any and all proceedings in this case, including the trial, order the entry of a final judgment, and
conduct all post-judgment proceedings.
Party Represented Signatures* Date
*Signatures may be electronically affixed (i.e. s/Judith Attorney) and, with consent so stated after the signature, counsel may
electronically sign for other counsel (i.e. s/John Attorney, by consent).
ORDER OF REFERENCE
IT IS ORDERED that this case be referred to
United States Magistrate Judge, to conduct all proceedings and order the entry of judgment in accordance with 28 U.S.C.
§636(c) and Fed.R.Civ.P. 73.
Date United States District Judge
NOTE: EFILETHIS
NOTE: EFILE THIS FORM
FORM WITH
WITH THE CLERK
THE CLERK OF THEOF THEONLY
COURT COURT ONLY
IF ALL IF ALL
PARTIES PARTIES
HAVE HAVETOCONSENTED
CONSENTED THE EXERCISETO
OFTHE
EXERCISE
JURISDICTION OF JURISDICTION
BY A UNITED BY A UNITED
STATES MAGISTRATE STATES
JUDGE AND SIGNEDMAGISTRATE
THIS FORM ASJUDGE.
SET OUT ABOVE.
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UNITED STATES DISTRICT COURT
FOR THE SOUTHERN DISTRICT OF ALABAMA
___________________
Southern DIVISION
[ Enter name(s) ]
______________________________,
Plaintiff, Case No.
v. [ Enter Case Number ]
______________________________
______________________________,
[ Enter name(s) ]
Defendant.
DISCLOSURE STATEMENT PURSUANT TO
FEDERAL RULE OF CIVIL PROCEDURE 7.1 AND CIVIL L.R. 7.1
Pursuant to Federal Rule of Civil Procedure 7.1 and Civil L.R. 7.1,
__________________________________________,
[ Name of Filer ] makes the following disclosure(s).
1. If the filer is a nongovernmental corporate party or a nongovernmental
corporation that seeks to intervene, either (i) identify any parent corporation
and any publicly held corporation owning 10% or more of its stock or (ii) state
there is no such corporation:
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
2. If this is an action in which jurisdiction is based on diversity under 28 U.S.C. §
1332(a), name and identify the citizenship of every individual or entity whose
citizenship is attributed to the filing party or intervenor: [To identify the
citizenship of a partnership, LLC, or other unincorporated entity, a party must
list the names and citizenships of all members or partners of that entity. See,
e.g., Rolling Greens MHP, L.P. v. Comcast SCH Holdings L.L.C., 374 F.3d 1020,
1022 (11th Cir. 2004).]
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
3. To the extent not otherwise disclosed above, if the filer is a nongovernmental
artificial entity appearing as a party or an amicus curiae, identify all parent
companies, subsidiaries, partners, limited liability entity members and
managers, trustees (but not trust beneficiaries), affiliates, or similar entities
reportable under the provisions of the S.D. Ala. Civil L.R. 7.1:
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
☐ I certify that, except as disclosed, I am unaware of an actual or potential
conflict of interest affecting the district judge or the magistrate judge in this action, and
that I will amend this Disclosure Statement promptly upon learning of any relevant
changes or corrections.
_______________________ _______________________________
Date Counsel Signature
_______________________________
Counsel for (print party names)
_______________________________
Address, City, State, Zip Code
Local Form For Report of Parties' Planning Meeting
IN THE UNITED STATES DISTRICT COURT
FOR THE SOUTHERN DISTRICT OF ALABAMA
SOUTHERN DIVISION
___________________________, :
Plaintiff, :
vs. : CIVIL ACTION _________________
___________________________, :
Defendant. :
REPORT OF PARTIES' PLANNING MEETING
Pursuant to Fed.R.Civ.P. 26(f), a meeting was held on (date) at (place) and was attended by:
(name) for plaintiff(s)
(name) for defendant(s) (party name)
(name) for defendant(s) (party name)
The parties [request] [do not request] a conference with the court before entry of thescheduling order.
1. Plaintiff's brief narrative statement of the facts and the cause of action stated in
each count, and defendant's brief narrative statement of the facts and defenses, including affirmative
defenses, stating the theory of each defense. In other words, the parties are to fully state their present
respective positions in plain English, given what they know about the case at this time. This is not to
be simply a restatement of the complaint and answer.
2. This [jury] [non-jury] action should be ready for trial by (date) and at this time is
expected to take approximately (length of time in days excluding jury selection).
3. The parties request a pretrial conference in (month and year).
4. Discovery Plan. The parties jointly propose to the court the following discovery
plan: [Use separate paragraphs or subparagraphs as necessary if parties disagree.]
Discovery will be needed on the following subjects: (brief description of subjects
on which discovery will be needed).
All discovery commenced in time to be completed by (date). [Discovery on (issue for early
discovery) to be completed by (date).]
5. Initial Disclosures. The parties [have exchanged] [will exchange by (date)] the
information required by Fed.R.Civ.P. 26(a)(1).
6. The parties request until (date) to join additional parties and amend the pleadings.
7. Reports from retained experts under Rule 26(a)(2) due:
from plaintiff(s) by (date).
from defendant(s) by (date).
8. Pretrial Disclosures. Final lists of witnesses and exhibits under Rule 26(a)(3)
due by (date).
9. Discovery Limits.
Maximum of ___ interrogatories by each party to any other party. Responses due
___ days after service.
Maximum of ___ depositions by plaintiff(s) and ___ by defendant(s). Each
deposition limited to maximum of ___ hours unless extended by agreement of
parties.
Maximum of ___ requests for admission by each party to any other party.
Responses due ___ days after service.
Maximum of ___ requests for production of documents by each party to any other
party. Responses due ___ days after service.
10. All potentially dispositive motions filed by (date).
11. Settlement [is likely] [is unlikely] [cannot be evaluated prior to (date)] [may be
enhanced by use of the following alternative dispute resolution procedure: [___].
12. The discovery in this action [will] [will not] include Electronically Stored
Information (ESI). In those cases where discovery of ESI is a probability, the
parties shall discuss the substantive issues of the existence and location of the
ESI, the preservation (including time period) of information, the ease/difficulty
and costs of production, a schedule and format for production, and a plan for how
to manage privilege and work product protection issues. An ESI production
agreement as to how to manage these issues shall be included in the Report. If the
parties cannot agree on an ESI production agreement, the disagreements are to be
listed in the Report.
13. [Other matters that may be appropriate for inclusion in the Rule 16(b) Order.]
Date: __________
Signature1 Signature1
Name Name
Counsel for Plaintiff Counsel for Defendant
Address Address
Telephone Number Telephone Number
Signatures may be electronically affixed (i.e. s/Judith Attorney) and, with consent so stated after
the signature, counsel may electronically sign for other counsel (i.e. s/John Attorney, by consent).
Summons in a Social Security Action
UNITED STATES DISTRICT COURT
for the
__________ District of __________
)
)
Plaintiff
)
v. ) Civil Action No.
)
)
Defendant
)
SUMMONS IN A CIVIL ACTION
To: (Defendant’s name and address)
A lawsuit has been filed against you.
Within 90 days after service of this summons on you (not counting the day you received it), you must serve on the
plaintiff an answer to the attached complaint or a motion under Rule 12 of the Federal Rules of Civil Procedure. The answer
or motion must be served on the plaintiff or plaintiff’s attorney, whose name and address are:
If you fail to respond, judgment by default will be entered against you for the relief demanded in the complaint.
You also must file your answer or motion with the court.
CHARLES R. DIARD, JR., CLERK OF COURT
Date:
Signature of Clerk or Deputy Clerk
AO 440 (Rev. 12/09) Summons in a Civil Action (Page 2)
Civil Action No.
PROOF OF SERVICE
(This section should not be filed with the court unless required by Fed. R. Civ. P. 4 (l))
This summons for (name of individual and title, if any)
was received by me on (date) .
’ I personally served the summons on the individual at (place)
on (date) ; or
’ I left the summons at the individual’s residence or usual place of abode with (name)
, a person of suitable age and discretion who resides there,
on (date) , and mailed a copy to the individual’s last known address; or
’ I served the summons on (name of individual) , who is
designated by law to accept service of process on behalf of (name of organization)
on (date) ; or
’ I returned the summons unexecuted because ; or
’ Other (specify):
.
My fees are $ for travel and $ for services, for a total of $ 0.00 .
I declare under penalty of perjury that this information is true.
Date:
Server’s signature
Printed name and title
Server’s address
Additional information regarding attempted service, etc:
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UNITED STATES DISTRICT COURT
SOUTHERN DISTRICT OF ALABAMA
*
*
_______________________________________ *
Plaintiff(s), *
vs. * CASE NO._____________________________
*
*
_______________________________________ *
Defendant(s). *
EXHIBITS
FOR
ADMITTED
IDENTIFICATION
IN
ONLY
EVIDENCE
CRIMINAL
IN THE UNITED STATES DISTRICT COURT
FOR THE SOUTHERN DISTRICT OF ALABAMA
SOUTHERN DIVISION
UNITED STATES OF AMERICA *
vs. * CRIMINAL NO.
*
CONSENT TO PROCEED BEFORE A
UNITED STATES MAGISTRATE JUDGE FOR
SELECTION OF THE JURY IN A
FELONY CASE
The parties to this action hereby waive their right to proceed before a United States
district judge and consent to have a United States magistrate judge conduct voir dire and
supervise the selection of the jury in this action. The opportunity to seek de novo review of any
decision of the Magistrate Judge made during jury selection to a district judge is also expressly
waived. An appeal of jury selection decisions will lie to the court of appeals as it would if made
by a district judge.
DEFENDANT Date
COUNSEL FOR DEFENDANT Date
COUNSEL FOR GOVERNMENT Date
ORDER OF REFERENCE
It is hereby ORDERED that this action be referred to U.S. Magistrate Judge _________
for the selection of the jury pursuant to 28 U.S.C. ' 636(b)(3) and Local Rule 72.1. See Peretz
v. United States, 501 U.S. 923, 111 S.Ct. 2661, 115 L.Ed.2d 808 (1991). Any appeal of a
decision of the magistrate judge made during jury selection will lie to the court of appeals as it
would if made by a district judge.
DONE this the day of , .
UNITED STATES DISTRICT JUDGE
IN THE UNITED STATES DISTRICT COURT FOR THE
SOUTHERN DISTRICT OF ALABAMA
SOUTHERN DIVISION
UNITED STATES OF AMERICA *
vs. * CR. NO.
*
*
NOTICE OF INTENT TO PLEAD GUILTY
Comes now the defendant in the above-styled cause and hereby gives notice of his/her intent to
plead guilty to count(s) of the indictment in this cause.
This change of plea is based on plea negotiations with the U.S. Attorney. As a result of these plea
negotiations and in exchange for my plea of guilty, the Government has agreed to recommend to the Court
the following:
However, I understand that pursuant to the provisions of Rule 11(e)(1)(B) F.R.Cr.P., a recommendation
of the U.S. Attorney pursuant to this plea agreement is not binding upon the Court. I further understand
that if my plea of guilty is offered based upon a recommendation of the U.S. Attorney, I will have no right
to withdraw my plea of guilty if the Court elects not to accept the recommendation of the U.S. Attorney.
I further understand that I am scheduled to enter my plea on
20 at a.m./ p.m. before United States District Judge .
Date:
Defendant
Attorney for the Defendant
Attorney for the Government
UNITED STATES DISTRICT COURT
FOR THE SOUTHERN DISTRICT OF ALABAMA
_________________DIVISION
UNITED STATES OF AMERICA *
*
VS. * CR. ACTION NO. _____________________
*
______________________________ *
Defendant’s Name *
CERTIFICATION REGARDING THE PRELIMINARY GUIDELINE
CALCULATIONS OF THE PROBATION OFFICER
The Court, during the arraignment hearing, directed the United States Probation Officer
to prepare preliminary calculations, consistent with United States Sentencing Guidelines, as an
aide to the parties’ efforts to determine the range of possible sentences that could be imposed
should the defendant be found guilty on any pending charge. It was intended that the Court, the
defendant, defendant’s attorney and the Assistant United States Attorney, would have had an
opportunity to examine the report on preliminary calculations prior to the pretrial conference. It
was also recognized that the calculations would be based on the Probation Officer’s review of
the relevant information available to the Probation Officer at the time his report is completed and
filed.
The Probation Officer in this action has completed the preliminary guideline calculations
and they have been shared with the parties. After receipt and review of these preliminary
calculations, counsel certifies to the following:
1. A copy of the Probation Officer’s report containing the preliminary guideline
calculations has been shown to the defendant and we discussed the guideline calculations
contained in the report;
2. I have provided the defendant with an independent assessment of the preliminary
guideline calculations contained in the report;
3. The defendant has been given an opportunity to ask questions regarding the
preliminary guideline calculations and I have responded to those questions; and
4. The defendant was advised that the preliminary guideline calculations contained
in the report are based on the Probation Officer’s review of the relevant information available to
him/her at the time the report was completed and filed, and that the United States Sentencing
Guidelines are advisory and do not bind the Court. Furthermore, the defendant was also advised
that the preliminary guideline calculations might be different from the final calculations in the
event he/she is found guilty on any pending charge and a presentencing report is ordered.
I certify under the penalty of perjury that the foregoing is true and correct on this the
________ day of ______________, 2014.
____________________________________
Attorney’s Signature
____________________________________
Attorney’s Name Printed
Attorney for Defendant _______________
UNITED STATES DISTRICT COURT
FOR THE SOUTHERN DISTRICT OF ALABAMA
______________ DIVISION
UNITED STATES OF AMERICA *
*
VS. * CR. ACTION NO. ___________________
*
_______________________________ *
*
Defendant. *
WAIVER OF RIGHT TO A SPEEDY TRIAL
I understand that I have the right to have my trial commence within the time required by
the Speedy Trial Act, 18 U.S.C. § § 3161-3174, but have elected to have that time period
extended.
I, being fully advised of my rights regarding a speedy trial, knowingly, intelligently and
voluntarily waive (GIVE UP) my right to a speedy trial. This decision has been made after I:
(A) was advised by my attorney of the reasons for seeking a continuance;
(B) became aware that the time requested in the extension may be excluded
from any calculation of time under the Speedy Trial Act; and
(C) with full understanding and knowledge, have agreed to the extension of
time that has been requested.
I certify under the penalty of perjury that the foregoing is true and correct on this the
________ day of ______________, 2014.
______________________________________________
DEFENDANT’S NAME
APPROVED BY:
______________________________________________
ATTORNEY’S NAME
ATTORNEY FOR DEFENDANT
UNITED STATES DISTRICT COURT
FOR THE SOUTHERN DISTRICT OF ALABAMA
)
)
________________________________ )
)
vs. ) Criminal Action No._______________
)
)
________________________________ )
CRIMINAL DISCLOSURE STATEMENT
Pursuant to Criminal Local Rule 12.4 of the Southern District of
Alabama and to enable Judges and Magistrate Judges to evaluate possible
disqualification or recusal, the undersigned counsel for
_____________________________________________________________________
certifies as follows:
(1) Non-governmental Parties and Amici Curiae.
A. state the full name of every party or amicus the attorney represents in
the action; and
B. if such party or amicus is a corporation:
i. identify any parent corporation and any publicly held corporation
owning 10% or more of its stock; or
ii. state there is no such corporation; and
C. state the names of all law firms whose attorneys will appear, or are
expected to appear, for the party in this Court.
.
ALSD Rev. 5/2014
(2) Organizational Victims.
A. state the full name of every victim that has been identified; and
B. if such victim is a corporation:
i. identify any parent corporation and any publicly held
corporation owning 10% or more of its stock; or
ii. state there is no such corporation.
.
_________________________________ ______________________________
Date Signature of Attorney
2 ALSD Rev. 5/2014
PRISONER
IN THE UNITED STATES DISTRICT COURT FOR THE
SOUTHERN DISTRICT OF ALABAMA
PRISONER COMPLAINT
[FOR INMATE ACTION] UNDER 42 U.S.C. § 1983
____________________________________
Name under which you were convicted
____________________________
Your prison number
CIVIL ACTION NO. __________________
vs. (To be supplied by Clerk of Court)
____________________________
Name of Defendant(s)
_________________________________________________________________
Place of Confinement and Address
INSTRUCTIONS - READ CAREFULLY
A. Complaint Form. You must file your original complaint and a copy for each named Defendant.
Your complaint must be clearly handwritten or typewritten. Do not use the back of a page. Your
complaint must be signed by you; no notary is required. Any false statement of material fact may
serve as the basis for prosecution for perjury.
B. Proper Court. Your complaint can only be brought in this Court if a defendant is located in the
Southern District of Alabama and the rest of the defendants are located in Alabama or if your claim
arose in this district. The Southern District of Alabama is comprised of the following counties:
Baldwin, Clarke, Choctaw, Conecuh, Dallas, Escambia, Hale, Marengo, Mobile, Monroe, Perry,
Washington, and Wilcox.
C. Separate Case. It is necessary to file a separate complaint form for each claim unless the claims
are related to the same incident or issue.
D. Defendants. The persons who are listed as defendants in section III of the complaint are deemed
by the Court to be the only defendants to this action. A defendant's present address must be
provided. The Court is unable to serve process without the present address being furnished. The first
defendant listed in section III should be the defendant that you list in the style of your case on your
complaint form and motion to proceed without prepayment of fees and costs, if applicable, and any
other pleading filed with the Court.
Rev. 8/1/15
E. Pleading the Complaint. Your complaint should not contain legal arguments, case law or statutory
citations. You are required to provide facts. Your complaint shall be a short and plain statement of
your claim and shall provide fair notice to each defendant of the claim against that defendant and of
the factual grounds upon which the claim rests.
F. Fees. This complaint cannot be properly filed unless it is accompanied by the $400.00 filing fee, or
a motion to proceed without prepayment of fees if you are unable to afford the filing fee and other
costs associated with prosecuting this action. If IFP is granted the filing fee is $350.00.
If you are unable to pay the filing fee and service costs for this action, you may ask the Court
to let you proceed without prepayment of fees and costs. A blank motion for this purpose is included.
If you wish to proceed without prepayment of fees and costs, you must complete and mail to
the Clerk of Court a copy of the "Motion to Proceed Without Prepayment of Fees" mailed to you with
this complaint. This motion will be returned to you without action unless you have an authorized
officer at the jail or prison complete the financial statement mailed to you with this form.
Even if the Court authorizes you to proceed without prepayment of filing fees, you are
obligated to pay the full $350.00. If you have the ability to pay a partial filing fee when your
complaint is filed, you will be required to pay an amount, based on your assets, of up to the greater of
20 percent of your average monthly balance in your prison account or your average monthly balance
for six months immediately preceding the filing of your complaint. Thereafter, your prison account
will be garnished at the rate of 20 percent of your monthly income until the filing fee is paid.
G. Form of Pleadings. All pleadings and other papers filed must be on 8 1/2" x 11" paper, legibly
handwritten or typewritten. Every document filed after the complaint must have the style of the case
and the docket number. Every pleading must be signed by you and must contain your address and
telephone number, if any; otherwise, the pleading will be stricken. See Fed. R. Civ. P. 11(a). No
notary is required.
H. Certificate of Service. Each pleading filed after the complaint must contain a certificate of service
indicating that the pleading has been served on the opposing parties and the date that it was sent. A
pleading will be stricken if it does not contain this certificate of service. See Fed. R. Civ. P. 5.
I. Copies. This Court will not make copies of your complaint or pleadings unless you prepay the
required per page copying fee.
J. Form of Pleadings. Do not write letters to the Court. All pleadings and documents should be sent
to the Clerk of the Court, and not to a magistrate judge or a district judge.
K. No Evidence. No evidence shall be sent to the Court for filing or storing.
I. PREVIOUS LAWSUITS.
A. Have you filed any other lawsuits in state or federal court dealing with the same or similar facts
involved in this action:
Yes ( ) No ( )
B. Have you filed other lawsuits in state or federal court relating to your imprisonment:
Yes ( ) No ( )
C. If your answer to questions A or B above is yes, describe each lawsuit in the space below. (If
there is more than one lawsuit, describe the additional lawsuits on another piece of paper, using this
same outline.)
1. Parties to this previous lawsuit:
Plaintiffs:
Defendants:
2. Court (if federal court, name the district; if state court, name the county):
3. Docket Number:
4. Were you granted the opportunity to proceed without payment of filing fees?
Yes ( ) No ( )
5. Name of judge to whom the case was assigned:
6. If your case is no longer pending and has been dismissed, state the reason given by the
Court as to why your case was dismissed, i.e., frivolous, malicious, failed to state a claim,
defendants were immune, etc.
7. Approximate date of filing lawsuit:
8. Approximate date of ruling by court:
II. YOUR PRESENT COMPLAINT.
A. Place or institution where action complained of occurred:
B. Date it occurred:
C. Is there a prisoner grievance procedure in this institution?
D. Did you present the facts relating to your complaint in the state prisoner grievance procedure?
Yes ( ) No ( )
E. If your answer is YES:
1. What steps did you take?
2. What was the result?
F. If your answer is NO, explain why not:
G. Your claim (briefly explain your claim: what, when, where, who; do not cite cases; you may,
without leave of Court, add up to five (5) additional pages if necessary):
III. PARTIES.
A. Plaintiff (Your name/AIS):
Your present address:
B. Defendant(s):
1. Defendant (full name) is employed as at .
His/her present address is .
(a) Claim against this defendant:
.
(b) Supporting facts (Include date/location of incident):
2. Defendant (full name) is employed as
at .
His/her present address is .
(a) Claim against this defendant:
.
(b) Supporting facts (Include date/location of incident):
3. Defendant (full name) is employed as
at .
His/her present address is .
(a) Claim against this defendant:
.
(b) Supporting facts (Include date/location of incident):
C. Additional Defendants: (If there are additional defendants, you may list them on separate pages
using the same outline above).
IV. A. You must answer the following questions:
1. State the conviction(s) for which you are presently incarcerated:
.
2. When were you convicted?
3. What is the term of your sentence?
4. When did you start serving this sentence?
5. Do you have any other convictions which form the basis of a future sentence?
Yes ( ) No ( )
If so, complete the following:
(a) Date of conviction:
(b) Term of sentence:
6. What is your expected end of sentence (E.O.S.) date?
B. If this present lawsuit concerns your criminal conviction or sentence,
state whether your conviction has been:
Conviction Sentence
Reversed yes( ) no( ) yes( ) no( )
Expunged yes( ) no( ) yes( ) no( )
Invalidated yes( ) no( ) yes( ) no( )
Writ of habeas yes( ) no( ) yes( ) no( )
corpus granted
C. If you answered yes to any of the questions, state the Court or entity that relieved you from your
conviction or sentence and the date:
V. State briefly exactly what you want the Court to do for you if you win (make no legal argument,
cite no cases or statutes):
VI. AFFIRMATION. By my signature below, I swear or affirm under penalty of perjury that the
facts set out in this complaint are true and correct.
Date (Signature of Plaintiff Under Penalty of Perjury)
Current Mailing Address
Telephone Number
PLAINTIFF SHALL IMMEDIATELY ADVISE THE COURT IN WRITING OF ANY CHANGE IN
HIS ADDRESS, E.G., RELEASED, TRANSFERRED, MOVED, ETC. FAILURE TO NOTIFY THE
COURT OF A NEW ADDRESS WILL RESULT IN THE DISMISSAL OF THIS ACTION FOR
FAILURE TO PROSECUTE AND TO OBEY THE COURT'S ORDER.
IN THE UNITED STATES DISTRICT COURT FOR THE
SOUTHERN DISTRICT OF ALABAMA
Name
Prison Number
Place of Confinement
Action No.
(To be supplied by Clerk of U. S. District Court)
(PETITIONER)
(Full name under which you were convicted)
v.
(RESPONDENT)
(Name of Warden, Superintendent, Jailor, or authorized person having custody of petitioner)
PETITION FOR WRIT OF HABEAS CORPUS BY A
PERSON IN STATE CUSTODY
Instructions - Read Carefully
(1) This petition must be legibly handwritten or typewritten, and signed by the petitioner under
penalty of perjury. Any false statement of a material fact may serve as the basis for prosecution and
conviction for perjury. All questions must be answered concisely in the proper space on the form.
(2) Additional pages are not permitted except with respect to the facts which you rely upon to
support your grounds for relief. No citation of authorities need be furnished. If briefs or arguments
are submitted, they should be submitted in the form of a separate memorandum.
(3) Upon receipt of a fee of $5, your petition will be filed if it is in proper order.
(4) If you do not have the necessary filing fee, you may request permission to proceed in forma
pauperis, in which event you must complete the "Motion to Proceed Without Prepayment of Fees
and Costs" form mailed to you with this form, and have an authorized officer at the jail or prison
complete the attached financial statement. The completed forms must be returned to the federal
court clerk in Mobile.
(5) Only convictions entered by one court at the same time may be challenged in a single petition.
If you seek to challenge convictions entered by different courts in the same state or in different
states, you must file separate petitions as to each court.
Revised /201
(6) Your attention is directed to the fact that you must include all grounds for relief and all facts
supporting such grounds for relief in the petition you file seeking relief from any judgment of
conviction.
(7) When the petition is fully completed, the original and two copies must be mailed to the Clerk
of the United States District Court whose address is 113 Saint Joseph Street, Mobile, Alabama
36602.
(8) Petitions which do not conform to these instructions will be returned with a notation as to the
deficiency.
(9) You must immediately advise the Court of any change in your address, e.g., if you are released,
transferred, moved, etc. Failure to notify the Court of your new address will result in the dismissal
of this petition for failure to prosecute and to obey the Court's order.
PETITION
1. Name and location of court which entered the judgment of conviction under attack: Circuit Court
of County, Alabama; Case Number ;
Judge . Other court, and case number, if not Circuit Court:
.
2. Date of judgment of conviction
3. Length of sentence
4. Nature of offense involved (all counts)
5. What was your plea? (Check one)
(a) Not guilty
(b) Guilty
(c) Nolo contendere
6. Kind of trial: (Check one)
(a) Jury
2 Revised /201
(b) Judge only
7. Did you testify at the trial? Yes No
8. Did you appeal from the judgment of conviction? Yes No
9. If you did not appeal, explain briefly why you did not: _______________________________
10. If you did appeal, answer the following:
(a) Name of court
(b) Result
(c) Date of result
(d) Did you file a petition for rehearing?
Yes No ; if yes, what was the result?
________________________________________________________________________
When did the court rule on your petition?
(e) Did you file a petition for certiorari?
Yes No ; if yes, what was the result?
When did the court rule on your petition?
11. Other than a direct appeal from the judgment of conviction and sentence, have you
previously filed any petitions (Rule 20, Rule 32, Error Coram Nobis, Habeas Corpus), applications,
or motions with respect to this judgment in any state court?
Yes No
12. If your answer to 11. was "yes," give the following information:
3 Revised /2015
(a)(1) Name of court Date filed
(2) Nature of proceeding (Rule 32, Rule 20, etc.)
(3) Grounds raised
(4) Did you receive an evidentiary hearing on your petition, application, or motion?
Yes No
(5) Result
(6) Date of result
(b) As to any second petition, application or motion, give the same information:
(1) Name of court Date filed
(2) Nature of proceeding
(3) Grounds raised
(4) Did you receive an evidentiary hearing on your petition, application, or motion?
Yes No
(5) Result
(6) Date of result
(c) As to any third petition, application or motion, give the same information:
(1) Name of court Date filed
(2) Nature of proceeding
4 Revised 8/2015
(3) Grounds raised
(4) Did you receive an evidentiary hearing on your petition, application, or motion?
Yes No
(5) Result
(6) Date of result
(d) Did you appeal the result of action taken on any petition, application or motion to the
highest state court having jurisdiction?
(1) First petition, etc. Yes No
Date filed Result
Date of result
(2) Second petition, etc. Yes No
Date filed: Result:
Date of result
(3) Third petition, etc. Yes No
Date filed Result
Date of result
(e) If you did not appeal from the adverse action on any petition, application or motion,
explain briefly why you did not:
13. State concisely every ground on which you claim that you are being held unlawfully.
Summarize briefly the facts supporting each ground. If necessary, you may attach pages stating
additional grounds and facts supporting same.
Caution: In order to proceed in the federal court, you must first exhaust your state court
5 Revised 8/2015
remedies as to each ground on which you request action by the federal court. Also, if you fail to set
forth all grounds in this petition, you may be barred from presenting additional grounds at a later
date.
For your information, the following is a list of the most frequently raised grounds for relief
in habeas corpus proceedings. Each statement preceded by a letter constitutes a separate ground for
possible relief. You may raise any grounds which you may have other than those listed if you have
exhausted your state court remedies with respect to them. However, you should raise in this petition
all available grounds (relating to this conviction) on which you base your allegations that you are
being held in custody unlawfully.
Do not check any of these listed grounds. If you select one or more of these grounds for
relief, you must allege facts. The petition will be returned to you if you merely check (a) through
(j) or any one of these grounds.
(a) Conviction obtained by plea of guilty which was unlawfully induced or not made
voluntarily with understanding of the nature of the charge and the consequences of the plea.
(b) Conviction obtained by use of coerced confession.
(c) Conviction obtained by use of evidence gained pursuant to an unconstitutional search
and seizure.
(d) Conviction obtained by use of evidence obtained pursuant to an unlawful arrest.
(e) Conviction obtained by a violation of the privilege against self-incrimination.
(f) Conviction obtained by the unconstitutional failure of the prosecution to disclose to the
defendant evidence favorable to the defendant.
(g) Conviction obtained by a violation of the protection against double jeopardy.
(h) Conviction obtained by action of a grand or petit jury which was unconstitutionally
selected and impaneled.
(I) Denial of effective assistance of counsel.
(j) Denial of right of appeal.
A. Ground one:
1. Supporting FACTS (tell your story briefly without citing cases or law):
6 Revised 8/2015
2. Did you raise this claim before the state courts on:
Direct appeal: Yes No
Rule 20/32 Petition: Yes No
Error Coram Nobis: Yes No
State Habeas Corpus: Yes No
3. If you did not raise this claim before the state courts, tell why you did not:
B. Ground two:
1. Supporting FACTS (tell your story briefly without citing cases or law):
2. Did you raise this claim before the state courts on:
Direct appeal: Yes No
Rule 20/32 Petition: Yes No
Error Coram Nobis: Yes No
State Habeas Corpus: Yes No
3. If you did not raise this claim before the state courts, tell why you did not:
7 Revised 8/2015
C. Ground three
1. Supporting FACTS (tell your story briefly without citing cases or law):
2. Did you raise this claim before the state courts on:
Direct appeal: Yes No
Rule 20/32 Petition: Yes No
Error Coram Nobis: Yes No
State Habeas Corpus: Yes No
3. If you did not raise this claim before the state courts, tell why you did not:
D. Ground four:
1. Supporting FACTS (tell your story briefly without citing cases or law):
2. Did you raise this claim before the state courts on:
Direct appeal: Yes No
Rule 20/32 Petition: Yes No
Error Coram Nobis: Yes No
State Habeas Corpus: Yes No
8 Revised 8/2015
3. If you did not raise this claim before the state courts, tell why you did not:
14. A. Have any of the grounds listed in this present habeas corpus petition ever been raised by
you in any other federal habeas corpus petition? Yes No . If yes, which
grounds?
State the name and case number of your previous federal habeas corpus petition:
B. Have you previously filed a habeas corpus petition attacking this present conviction in
this or any other federal court? Yes No . If yes, state the name and case
number of your previous federal habeas corpus petition:
15. Do you have any petition or appeal now pending in any court, either state or federal, as to the
judgment under attack? Yes No . If yes, name the court:
and state the name and case number of the petition or appeal:
16. Give the name and address, if known, of each attorney who represented you in the following
stages of the judgment attacked herein:
(a) At preliminary hearing
(b) At arraignment and plea
(c) At trial
9 Revised 8/2015
(d) At sentencing
(e) On appeal
(f) In any post-conviction proceeding
(g) On appeal from any adverse ruling in a post-conviction proceeding
17. Were you sentenced on more than one count of an indictment, or on more than one indictment,
in the same court and at the same time? Yes No
18. Do you have any future sentence to serve after you complete the sentence imposed by the
judgment under attack? Yes No
(a) If so, give name and location of court which imposed sentence to be served in the future:
(b) And give date and length of sentence to be served in the future:
(c) Have you filed, or do you contemplate filing, any petition attacking the judgment which
imposed the sentence to be served in the future? Yes No
19. TIMELINESS OF PETITION: This petition is subject to a one-year statute of limitations
contained in The Antiterrorism and Effective Death Penalty Act of 1996 (“AEDPA”), 28 U.S.C. §
2244(d):
(1) A one-year period of limitation shall apply to an application for a writ of habeas
corpus by a person in custody pursuant to the judgment of a State court. The
limitation period shall run from the latest of –
(A) the date on which the judgment became final by the conclusion of direct
review or the expiration of the time for seeking such review;
(B) the date on which the impediment to filing an application created by State
action in violation of the Constitution or laws of the United States is removed,
10 Revised 8/2015
if the applicant was prevented from filing by such state action;
(C) the date on which the constitutional right asserted was initially recognized
by the Supreme Court, if the right has been newly recognized by the Supreme
Court and made retroactively applicable to cases on collateral review; or
(D) the date on which the factual predicate of the claim or claims presented
could have been discovered through the exercise of due diligence.
(2) The time during which a properly filed application for State post-conviction or
other collateral review with respect to the pertinent judgment or claim is pending shall
not be counted toward any period of limitation under this subsection.
If your judgment of conviction became final over one year ago, you must explain, in the space
provided below, why the one-year statute of limitations contained in 28 U.S.C. § 2244(d) does not
bar your petition.
11 Revised 8/2015
Wherefore, petitioner prays that the Court grant petitioner relief to which he may be entitled
in this proceeding.
Signature of Attorney (if any)
Typed or printed name of attorney (if any)
I declare (or certify, verify, or state) under penalty of perjury that the foregoing is true and
correct. Executed and delivered to custodial authorities for mailing on
.
(date)
Signature of Petitioner
Current mailing address
12 Revised 8/2015
AO 242 (12/11) Petition for a Writ of Habeas Corpus Under 28 U.S.C. § 2241
PETITION FOR A WRIT OF HABEAS CORPUS UNDER 28 U.S.C. § 2241
Instructions
1. 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.
2. 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).
3. Preparing the Petition. The petition must be typed or neatly written, and you must sign and date it under
penalty of perjury. A false statement may lead to prosecution.
All questions must be answered clearly and concisely in the space on the form. If needed, you may attach
additional pages or file a memorandum in support of the petition. If you attach additional pages, number the
pages and identify which section of the petition is being continued. Note that some courts have page limitations.
All filings must be submitted on paper sized 8½ by 11 inches. Do not use the back of any page.
4. Supporting Documents. In addition to your petition, you must send to the court a copy of the decisions you are
challenging and a copy of any briefs or administrative remedy forms filed in your case.
5. Required Filing Fee. You must include the $5 filing fee required by 28 U.S.C. § 1914(a). If you are unable to
pay the filing fee, you must ask the court for permission to proceed in forma pauperis – that is, as a person who
cannot pay the filing fee – by submitting the documents that the court requires.
6. Submitting Documents to the Court. Mail your petition and copies to the clerk of the United States
District Court for the district and division in which you are confined. For a list of districts and divisions, see 28
U.S.C. §§ 81-131. All copies must be identical to the original. Copies may be legibly handwritten.
If you want a file-stamped copy of the petition, you must enclose an additional copy of the petition and ask the
court to file-stamp it and return it to you.
7. Change of Address. You must immediately notify the court in writing of any change of address. If you do not,
the court may dismiss your case.
Page 1 of 10
AO 242 (12/11) Petition for a Writ of Habeas Corpus Under 28 U.S.C. § 2241
UNITED STATES DISTRICT COURT
for the
__________ District of __________
)
)
)
Petitioner )
)
v. ) Case No.
) (Supplied by Clerk of Court)
)
)
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 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:
(b) Docket number of criminal case:
(c) Date of sentencing:
’ Being held on an immigration charge
’ Other (explain):
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AO 242 (12/11) Petition for a Writ of Habeas Corpus Under 28 U.S.C. § 2241
Decision or Action You Are Challenging
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:
(1) Name of the 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:
Page 3 of 10
AO 242 (12/11) Petition for a Writ of Habeas Corpus Under 28 U.S.C. § 2241
(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 the 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:
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 the 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:
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AO 242 (12/11) Petition for a Writ of Habeas Corpus Under 28 U.S.C. § 2241
(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:
(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?
’ 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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AO 242 (12/11) Petition for a Writ of Habeas Corpus Under 28 U.S.C. § 2241
(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:
(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:
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AO 242 (12/11) Petition for a Writ of Habeas Corpus Under 28 U.S.C. § 2241
(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 the authority, agency, or court:
(c) Date of filing:
(d) Docket number, case number, or opinion number:
(e) Result:
(f) Date of result:
(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:
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AO 242 (12/11) Petition for a Writ of Habeas Corpus Under 28 U.S.C. § 2241
(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.):
(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
Page 8 of 10
AO 242 (12/11) Petition for a Writ of Habeas Corpus Under 28 U.S.C. § 2241
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:
Request for Relief
15. State exactly what you want the court to do:
Page 9 of 10
AO 242 (12/11) Petition for a Writ of Habeas Corpus Under 28 U.S.C. § 2241
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
