Fill and Sign the Motion to Determine Factual Innocence Colorado Form

 County Court  District Court  Denver Juvenile Court ___________________________County, Colorado Court Address: State of Colorado v. Defendant: _____________________________ COURT USE ONLY Attorney or Party Without Attorney (Name and Address): Phone Number: E-mail: FAX Number: Atty. Reg. #: Case Number Division 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 Date  Drivers license number  Bank account records  Passport  Driver’s license  Other ( 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 Date Arrest or Summons Date Arrest or Summons Number Charge Description (identity each charge separately) Case Number Date of Conviction or indictment (if applicable) Charges Filed Yes/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 1 of 2 6.  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 country Date: ________________________________ _____________________________________ Signature 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 2