Court Opinion

ID: 4044259
Source: CourtListenerOpinion
Date Created: 2016-09-28 23:33:39.688839+00
Date Added: 2024-06-11T14:30:45.060852
License: Public Domain

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                                           2.
        PETITIONER'S INFORMATION

        Petitioner's printed name:

        State bar number, if applicable:

        Address:

        Telephone:,

       Fax:

        INMATE'S DECLARATION

        i,             fVkrh                        , am the applicant / petitioner (circle one) and

being presently incarcerated in A             i>7    (/UhtitAf Jt/5n&? , declare under penalty of

perjury that, according to my belief, the facts stated in the above application are true and correct.

                                                         Signed on       '3 Te b               20^.

                                                         Signature of Applicant / Petitioner (circle one)

                                                    17

                                                                                           Rev. 01/14/14
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                                  INMATE REQUEST FOR INFORMATION

                                                                      SID#
UNIT:                             MAIN JAIL:

                  CIRCLE ONE (1) SECTION ONLY OR REQUEST WILL BE VOIDED

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                                                       Information
                                                       Provided By:

                                                       Section:
        Inmate's Signature (Sign At Time Of Request)
                                                                         BCSOFORM351-171 REVFEB '13