Free Application to  Proceed In Forma Pauperis (Appendix B) - West Virginia

APPENDIX B POST-CONVICTION HABEAS CORPUS FORM APPLICATION TO PROCEED IN FORMA PAUPERIS AND AFFIDAVIT

STATE OF WEST VIRGINIA
Name Place of Confinement

County Prisoner No. Case No.

Name of Petitioner (include name under which convicted)

Name of Respondent (authorized person having custody of petitioner)

v.
NOTICE: This form is only to be used by incarcerated persons seeking post-conviction habeas corpus relief pursuant to W. Va. Code § 53-4A-1, et seq.

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I, ______________________________________________________________ declare that I am the petitioner in the above-entitled proceeding; that in support of my request to proceed without prepayment of fees or costs, I declare that I am unable to pay the costs of these proceedings and that I am entitled to the relief sought in the petition. In support of this application, I answer the following questions under penalty of perjury: 1. State the place of your incarceration ______________________________________________________________________ . Are you employed at the institution? __________ Do you receive any payment from the institution? __________ Have the institution fill out the Certificate portion of this application and attach a ledger sheet from the institution(s) of your incarceration showing at least the past six months' transactions. 2. In the past twelve months have you received any money from any of the following sources? a. Business, profession or other self-employment b. Rent payments, interest or dividends c. Pensions, annuities or life insurance payments d. Disability or workers compensation payments e. Gifts or inheritances f. Any other sources Yes Yes Yes Yes Yes Yes No No No No No No

If the answer to any of the above is "Yes" describe each source of money and state the amount received and what you expect you will continue to receive.

3. Other than any institutional accounts, do you have any cash, checking or savings accounts?

Yes

No

If "Yes" state the total amount ___________________________________________________________________________ . 4. Do you own any real estate, stocks, bonds, securities, other financial instruments, automobiles or other valuable property? Yes No

If "Yes" describe the property and state its value. _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ 5. List the persons who are dependent on you for support, state your relationship to each person and indicate how much you contribute to their support. _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ I declare under penalty of perjury that the above information is true and correct.

__________________________________
DATE

_____________________________________________________
SIGNATURE OF APPLICANT

CERTIFICATE
(To be completed by the institution of incarceration)

I certify that the applicant named herein has the sum of $____________________________ in a trustee spending account to his/her credit at (name of institution) ______________________________________________________________. I further certify that during the past six months the applicant's average balance was $____________________________, and the average of monthly deposits was $____________________________.

__________________________________
DATE

_____________________________________________________
SIGNATURE OF AUTHORIZED OFFICER