VIRGINIA:

IN THE _________________ COURT OF ___________________________________

___________________________________, # _________________
Full name and prison number

Petitioner,
v.

Case No.__________
(Court will supply No.)
_______________________________________
_______________________________________,
Full name and Title of Respondent

Respondent.

PETITION FOR WRIT OF HABEAS CORPUS

Instructions-Read Carefully
In order for this petition to receive consideration by the Court, it must be legibly handwritten or
type-written, signed by the petitioner and verified (notarized). It must set forth in concise form the answers
to each applicable question. If necessary, petitioner may finish his answer to a particular question on an
additional page. Petitioner must make it clear to which question any such continued answer refers.
Since every petition for habeas corpus must be sworn under oath, any false statement of a material
fact therein may serve as a basis of prosecution and conviction for perjury under 18.1-273. Petitioners
should, therefore, exercise care to assure that all answers are true and correct.
When the petition is completed, the original and two copies (total of three) should be mailed to the
Clerk of the Court. The petitioner shall also keep one copy.

NOTICE TO PETITIONER
The granting of the writ of habeas corpus does not entitle the petitioner to dismissal of the charges for the conviction of
which he is being detained, but may gain him no more than a new trial.

Place of detention: _____________________________________________________

A. Criminal Trial
1. Name and location of the court which imposed the sentence(s) from which you seek
relief:________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
2. The offense or offenses for which the sentence was imposed. (include indictment
number(s) if known):
a.___________________________________________________________________
b.___________________________________________________________________
c.___________________________________________________________________

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3. The date upon which sentence was imposed and the terms of the sentence:
a._________________________________________________________________
b._________________________________________________________________
c._________________________________________________________________
4. Check which plea you made and whether the trial was by jury or judge:
Plea of guilty____ Plea of not guilty ___; Trial by jury____ Trial by judge ___
5. The name and address of each attorney, if any, who represented you at your criminal
trial:
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
6. Did you appeal the conviction? ________________________________________
7. If you answered yes to 6, state:
The result and the date in your appeal or petition for certiorari:
a.________________________________________________________________
b.________________________________________________________________
The citations of the appellate court opinions or orders:
a._______________________________________________________________
b._______________________________________________________________
8. List the name and address of each attorney, if any, who represented you on your appeal:
________________________________________________________________
________________________________________________________________
B. Habeas Corpus
9. Before this petition, did you file with respect to this conviction any other petition for
habeas corpus in either a State or federal court? _____________

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10. If you answered yes to 9, list with respect to each petition:

The name and location of the court in which each was filed:
a._______________________________________________________________
b._______________________________________________________________
The disposition and the date:
a._______________________________________________________________
b._______________________________________________________________
The name and address of each attorney, if any, who represented you on your habeas corpus:
a._______________________________________________________________
b._______________________________________________________________
11. Did you appeal from the disposition of your petition for habeas corpus? _______
12. If you answered yes to 11, state:
The result and date of each petition
a._______________________________________________________________
b._______________________________________________________________
The citations of court opinions or orders on your habeas corpus petition:
a._______________________________________________________________
b._______________________________________________________________
The name and address of each attorney, if any, who represented you on appeal of your habeas corpus:
a.______________________________________________________________
b.______________________________________________________________

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C. Other Petitions, Motion or Applications

13. List all other petitions, motion or applications filed with any court following a final order
of conviction and NOT set out in sections A or B. Include the nature of the motion, the
name and location of the court, the result, the date, and citations to opinions or orders.
Give the name and address of each attorney, if any, who represented you:
a._________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
b._________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
c.__________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
d.__________________________________________________________________________
____________________________________________________________________________
___________________________________________________________________________
e.__________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
D Present Petition
14. State the grounds which make your detention unlawful, including the fact upon which
you intend to rely:
_________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________

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_________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
__________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
_________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
__________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________1

If this cause of action lies against the VA Department of Corrections for computation of the Petitioner's

Release Date, then this Court retains jurisdiction to hear this case under the decision in Caroll v.
Johnson, 278 Va. 683, 693, 685 S.E. 2d 647 (2009), stating "Rather Code 8.01-654(A)(1) allows the
petitioner to challenge the lawfulness of the entire duration of his or her detention, so long as an order
entered in the petitioner's favor, will result in a court order that will.....directly impact the duration of the
petitioner's confinement"

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15. List the grounds set forth in 14, which has been presented in any other proceeding:
a._____________________________________________________________
b._____________________________________________________________
c._____________________________________________________________
d._____________________________________________________________
e._____________________________________________________________
List the proceedings in which each ground was raised:
a.____________________________________________________________________________
b.____________________________________________________________________________
c.____________________________________________________________________________
d.____________________________________________________________________________
e.____________________________________________________________________________
16. If any ground set forth in 14 has not been presented to a court, list each ground and the reason why it
was not:
a.____________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
b._____________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
c._____________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
_________________________________
Signature of Petitioner
_________________________________________________
_________________________________________________
Address of Petitioner

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COMMONWEALTH OF VIRGINIA
CITY/COUNTY OF _________________________
The above named petitioner being first duly sworn, says:
a.
b.

He signed the foregoing petition; and

The facts stated in this petition are true to the best of his information and belief.
______________________________
Signature of Petitioner

This day the above signed person did appear before me and subscribed and sworn to before me this ____
day of _________________, 200__
______________________________
Notary Public
My Commission Expires: ________________________________
My Notary Number: ____________________________________
The petition will not be filed without payment of court costs unless the petitioner is entitled to proceed in forma pauperis and
has executed the attached.

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