Fill and Sign the Post Conviction Application Form

______________ : DOCKET NO. ______ & ______ PRISON NO. ______ : ______ JUDICIAL DISTRICT COURT ______ ______________ , WARDEN OF ______ PARISH CORRECTIONAL CENTER (Custodian) ______________________________________________________________________________ __ PETITION FOR POST-CONVICTION RELIEF . Name and location of Court which entered the Judgment of conviction challenged: ______ Judicial District Court, Parish of ______ , State of Louisiana. . Date of Judgment of conviction: ______ ___ , 20 ___ . . Length of sentence: ______ years at hard labor on Docket No. ______ , and ______ years at hard labor on Docket No. ______ . . Nature of offense involved: Docket No. ______ - ______________ ; Docket No. ______ - ______________ . . What was the nature of your plea? ______________ . (a) name and address of the lawyer representing you at your plea: ______________ ; ______________ , ______________ , Louisiana ______ , (b) was the lawyer appointed ( ) or hired ( )? . Kind of trial: ______________ . . (a) Name and address of the lawyer representing you at your trial: ______________ , ______________ , ______________ LA ______ . . Did you testify at trial? ______ . . (a) Give the name and address of the lawyer who represented you at sentencing for the conviction being attacked herein. ______________ ; ______________ , ______________ , Louisiana ______ . (b) Was the lawyer appointed ( ) or hired ( )? 2. Did you appeal from the judgment of conviction? ______ . 3. If you did appeal, give the following information: (a) Citation ______ , Docket No. ______ , date of written opinion by the Supreme Court if known, ______ ___ , 20 ___ . (b) Name and address of lawyer representing you on appeal: ______________ , ______________ , ______________ , LA ______ . (c) Was the lawyer appointed ( ) or hired ( )? . Other than a direct appeal from the judgment of conviction and sentence, have you previously filed any application for post conviction relief with respect to this judgment in any state or federal court? ______ . . If your answer to 12 is A yes @ , give the following information: ______________ . CLAIM FOR RELIEF 1. CLAIM: The conviction of the applicant was obtained in violation of the Constitution of the United States and State of Louisiana. (a) ______________ . (b) List of names and addresses of witnesses who could testify in support of your claim: ______________ ______________ ______________ ______________ 2. If any of the claims listed were not previously raised in the trial Court prior to conviction, on appeal or in a prior petition, application or motion, explain why: ______________ . 3. Do you have any petition, application, motion or appeal pending in any state or federal court as to the judgment under attack? ______ . 4. Do you have any future sentence to serve after you complete the sentence imposed by judgment under attack? ______ . WHEREFORE, petitioner prays that the Court grant his Petition for Post-Conviction Relief and any and all relief to which he may be entitled. Respectfully submitted, ______________________________ ______________ ______ Parish I.D. Board ______________ ______ , LA ______ ( ___ ) ______ Please serve the custodian, ______________ , and ______________ , District Attorney, ______ Judicial District, State of Louisiana. AFFIDAVIT I, ______________ , petitioner in the foregoing petition, do hereby declare, state and certify that the facts and allegations contained herein are true and correct to the best of my knowledge, information and belief, that I am presently incarcerated at the ______ Parish Correctional Center, ______________ , Louisiana; that due to this period of incarceration I am unable to pay the costs of this action; that I sincerely believe I am entitled to redress. This ________ day of _______________ 20 ___ , at ______________ , Louisiana. _____________________________ ______________ Signed before me on this _____ day of __________________ 20 ___ , in _______________, Louisiana. _______________________________ NOTARY PUBLIC CERTIFICATE I HEREBY CERTIFY that a copy of the above and foregoing pleading has been forwarded to all opposing counsel by hand delivering same. ______________ , Louisiana this _______ day of _________________, 20 ___ . ____________________________ ______________