Code of Virginia — Title 8.01 (Civil Remedies and Procedure), Chapter 25 (Extraordinary Writs)
§ 8.01-655. Form and contents of petition filed by prisoner.
A. Every petition filed by a prisoner seeking a writ of habeas corpus must be filed on the form set forth in subsection B. The failure to use such form and to comply substantially with such form shall entitle the court to which such petition is directed to return such petition to the prisoner pending the use of and substantial compliance with such form. The petitioner shall be responsible for all statements contained in the petition and any false statement contained therein, if the same be knowingly or wilfully made, shall be a ground for prosecution and conviction of perjury as provided for in § 18.2-434.

B. Every petition filed by a prisoner seeking a writ of habeas corpus shall be filed on a form to be approved and provided by the office of the Attorney General, the contents of which shall be substantially as follows:

IN THE............................................................… COURT

..........................................................................…

Full name and prisonerCase No............................…

number (if any) of(To be supplied by

Petitionerthe Clerk of the

-vs-Court)

..........................................................................…

..........................................................................…

Name and Title of 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 typewritten, signed by the petitioner and verified
before a notary or other officer authorized to administer oaths. 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. The petitioner may also submit exhibits.

Since every petition for habeas corpus must be sworn to under oath, any
false statement of a material fact therein may serve as the basis of
prosecution and conviction for perjury under § 18.2-434. 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 keep
one copy.

NOTICE

The granting of a writ of habeas corpus does not entitle the petitioner to
dismissal of the charges for 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 court which imposed the sentence from which you
seek relief:
..........................................................................…
....................................................................…..…

2. The offense or offenses for which sentence was imposed (include
indictment number or numbers if known):
a...................................................................…
b...................................................................…
c...................................................................…

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 trial by jury: Plea of guilty:
.......; Plea of not guilty:.......; Trial by jury:......; Trial by judge
without jury:...…

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...................................................................…
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?......…
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 the date of each
petition:
a...................................................................…
b...................................................................…
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...................................................................…

C. Other Petitions, Motions or Applications

13. List all other petitions, motions or applications filed with any court
following a final order of conviction and not set out in 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. Present Petition

14. State the grounds which make your detention unlawful, including the
facts on which you intend to rely:
a...................................................................…
b............…...................................................…
c...................................................................…
15. List each ground set forth in 14, which has been presented in any other
proceeding:
a...................................................................…
b...................................................................…
c...................................................................…
List the proceedings in which each ground was raised:
a...................................................................…
b...................................................................…
c...................................................................…
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

STATE OF VIRGINIA

CITY/COUNTY OF...................................…

The petitioner being first duly sworn, says:

1. He signed the foregoing petition;

2. The facts stated in the petition are true to the best of his
information and belief.

.............................................…

Signature of Petitioner

Subscribed and sworn to before me

this....… day of........................., 20...…

....................................…
Notary Public

My commission expires:......................…

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
affidavit in forma pauperis.

The petitioner who proceeds in forma pauperis shall be furnished, without
cost, certified copies of the arrest warrants, indictment and order of his
conviction at his criminal trial in order to comply with the instructions of
this petition.

AFFIDAVIT IN FORMA PAUPERIS

STATE OF VIRGINIA

CITY/COUNTY OF.............................…

The petitioner being duly sworn, says:

1. He is unable to pay the costs of this action or give security
therefor;
2. His assets amount to a total of $....................…

.............................................…

Signature of Petitioner

Subscribed and sworn to before me

this....… day of........................., 20...…

....................................…
Notary Public

My commission expires:..................…

Code 1950, § 8-596.1; 1968, c. 359; 1977, c. 617.