Fill and Sign the Motion to Determine Factual Innocence Form

JDF 223 R8-17 MOTION TO DETERMINE FACTUAL INNOCENCE PURSUANT TO §16-5-103, C.R.S. © 2017 Colorado Judicial Department for use in the Courts of Colorado Page 1 of 2County Court District Court Denver Juvenile Court___________________________County, ColoradoCourt Address: State of Coloradov.Defendant: _____________________________ COURT USE ONLY Attorney or Party Without Attorney (Name and Address): Phone Number: E-mail: FAX Number: Atty. Reg. #: Case NumberDivision Courtroom MOTION TO DETERMINE FACTUAL INNOCENCE This Motion is submitted pursuant to §16-5-103, C.R.S. for the purpose of determining factual innocence due to identity theft. 1. Information about the alleged victim of identity theft:Full Name: Date of Birth: Current Mailing Address: City, State & Zip:Home Phone #: Work Phone #: Cell #: 2. The following identifying information has been inappropriately obtained from the alleged victim of identity theft:Name Social security number Address Birth DateDrivers license number Bank account records Passport Driver’s licenseOther (specify): Other (specify): 3. The use of identifying information above has been mistakenly associated with an  arrest, summons, summons and complaint, felony complaint, information, indictment, or conviction. (Please check all that apply.)4. Name of Arresting Agency: 5.Identify specific information below and attach any affidavits, police reports, or any other relevant information:Offense DateArrest or Summons DateArrest or Summons Number Charge Description (identity each charge separately)Case Number Date of Conviction or indictment(if applicable)Charges FiledYes/No JDF 223 R8-17 MOTION TO DETERMINE FACTUAL INNOCENCE PURSUANT TO §16-5-103, C.R.S. © 2017 Colorado Judicial Department for use in the Courts of Colorado Page 2 of 26. If applicable, attached are copies of documents that verify my identity, e.g. social security card, birth certificate, passport. 7.If applicable, attached are copies of documents that support my whereabouts during the date and time of the offense. This may include; airline tickets, military records, a notarized statement from an employer, friend, etc. 8.If applicable, the alleged victim of identity theft has provided a copy of this Motion to the District Attorney’s Office.Wherefore, the alleged victim of identity theft requests this Court to determine factual innocence pursuant to §16-5-103, C.R.S. based on the information submitted. By checking this box, I am acknowledging I am filling in the blanks and not changing anything else on the form. By checking this box, I am acknowledging that I have made a change to the original content of this form.(Checking this box requires you to remove JDF number and copyright at the bottom of the form.) VERIFICATION AND ACKNOWLEDGEMENT I declare under penalty of perjury under the law of Colorado that the foregoing is true and correct.Executed on the ______ day of ________________, _______, at ______________________________________ (date) (month) (year) (city or other location, and state OR countryDate: ________________________________ _____________________________________ Signature