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7 T+e da!e upon %+i)+ sen!en)e %as imposed and !+e !erms o( !+e sen!en)e:

a_________________________________________________________________

b_________________________________________________________________

)_________________________________________________________________

C+e)/ %+i)+ plea &ou made and %+e!+er !+e !rial %as b& 1ur& or 1ude:

lea o( uil!&____ lea o( no! uil!& ___; Trial b& 1ur&____ Trial b& 1ude ___

id &ou appeal !+e )on"i)!ion? ________________________________________

6 I( &ou ans%ered @&es !o =, s!a!e:

T+e resul! and !+e da!e in &our appeal or pe!i!ion (or )er!iorari:

a________________________________________________________________

b________________________________________________________________

T+e )i!a!ions o( !+e appella!e )our! opinions or orders:

a_______________________________________________________________

b_______________________________________________________________

4 Bis! !+e name and address o( ea)+ a!!orne&, i( an&, %+o represen!ed &ou on &our appeal:

________________________________________________________________

________________________________________________________________

Habeas Corpus

D e(ore !+is pe!i!ion, did &ou (ile %i!+ respe)! !o !+is )on"i)!ion an& o!+er pe!i!ion (or

+abeas )orpus in ei!+er a 0!a!e or (ederal )our!? _____________

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3 I( &ou ans%ered @&es !o D, lis! %i!+ respe)! !o ea)+ pe!i!ion:

T+e name and lo)a!ion o( !+e )our! in %+i)+ ea)+ %as (iled:

a_______________________________________________________________

b_______________________________________________________________

T+e disposi!ion and !+e da!e:

a_______________________________________________________________

b_______________________________________________________________

T+e name and address o( ea)+ a!!orne&, i( an&, %+o represen!ed &ou on &our +abeas )orpus:

a_______________________________________________________________

b_______________________________________________________________

33 >id &ou appeal (rom !+e disposi!ion o( &our pe!i!ion (or +abeas )orpus? _______

35 I( &ou ans%ered @&es !o 33, s!a!e:

T+e resul! and da!e o( ea)+ pe!i!ion

a_______________________________________________________________

b_______________________________________________________________

T+e )i!a!ions o( )our! opinions or orders on &our +abeas )orpus pe!i!ion:

a_______________________________________________________________

b_______________________________________________________________

T+e name and address o( ea)+ a!!orne&, i( an&, %+o represen!ed &ou on appeal o( &our +abeas )orpus:

a______________________________________________________________

b______________________________________________________________

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C O!+er e!i!ions, o!ion or Appli)a!ions

37 Bis! all o!+er pe!i!ions, mo!ion or appli)a!ions (iled %i!+ an& )our! (ollo%in a (inal order

o( )on"i)!ion and NOT se! ou! in se)!ions A or In)lude !+e na!ure o( !+e mo!ion, !+e

name and lo)a!ion o( !+e )our!, !+e resul!, !+e da!e, and )i!a!ions !o opinions or ordersGi"e !+e name and address o( ea)+ a!!orne&, i( an&, %+o represen!ed &ou:

a_________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

b_________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

)__________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

d__________________________________________________________________________

____________________________________________________________________________

___________________________________________________________________________

e__________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

> resen! e!i!ion

3 0!a!e !+e rounds %+i)+ ma/e &our de!en!ion unla%(ul, in)ludin !+e (a)! upon %+i)+

&ou in!end !o rel&:_________________________________________________________________________

___________________________________________________________________________

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3I( !+is )ause o( a)!ion lies aains! !+e VA >epar!men! o( Corre)!ions (or )ompu!a!ion o( !+e e!i!ioners

Release >a!e, !+en !+is Cour! re!ains 1urisdi)!ion !o +ear !+is )ase under !+e de)ision in Caroll v.

Johnson, 564 Va =47, =D7, =4< 0E 5d =6 $5D', s!a!in Ra!+er Code 43*=

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COON9EABTH OF VIRGINIA

CITJCOUNT OF _________________________

T+e abo"e named pe!i!ioner bein (irs! dul& s%orn, sa&s:

a He sined !+e (oreoin pe!i!ion; and

b T+e (a)!s s!a!ed in !+is pe!i!ion are !rue !o !+e bes! o( +is in(orma!ion and belie(

______________________________0ina!ure o( e!i!ioner

T+is da& !+e abo"e sined person did appear be(ore me and subs)ribed and s%orn !o be(ore me !+is ____

da& o( _________________, 5__

______________________________

No!ar& ubli)

& Commission E8pires: ________________________________

& No!ar& Number: ____________________________________

T+e pe!i!ion %ill no! be (iled %i!+ou! pa&men! o( )our! )os!s unless !+e pe!i!ioner is en!i!led !o pro)eed in forma pauperisand

+as e8e)u!ed !+e a!!a)+ed

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