Va. Sup. Ct. R. pt. 5A, Form 10

PETITION FOR A WRIT OF ACTUAL INNOCENCE BASED ON

NONBIOLOGICAL EVIDENCE

THE COURT OF APPEALS OF VIRGINIA

____________________________________ Record No. _________________________

(FULL NAME OF PETITIONER AND (TO BE SUPPLIED BY THE CLERK

PRISONER NO., IF APPLICABLE) OF THE COURT OF APPEALS)

v.

Commonwealth of Virginia

(RESPONDENT)

(PETITIONER'S ADDRESS)

Pursuant to the provisions of Chapter 19.3 of Title 19.2 of the Code of

Virginia, I, _________________________________________________________________

NAME OF PETITIONER

hereby petition this Court for a WRIT OF ACTUAL INNOCENCE BASED ON NONBIOLOGICAL

EVIDENCE. In support of this petition, I state under oath that the following information is true:

1. On ____________________________ , I was convicted or adjudicated delinquent in the

__________________________________ Circuit Court of the following offense(s):

JURISDICTION (CITY/COUNTY)

Description of Virginia Code Circuit Court Plea

Felony Offense Case No.

2. I am innocent of the offenses(s) that are the subject of this petition.

3. My claim of innocence is based upon the following evidence:

[] ATTACHED ADDITIONAL SHEET(S)

4. Check all that apply:

[] (a) This evidence was previously unknown or unavailable to either me or my attorney at

the time the conviction(s) or adjudication(s) of delinquency became final in the circuit court;

and/or

[] (b) This evidence was not subject to scientific testing because _____________________

5. This evidence became known or available to me on ________________________.

DATE

6. The circumstances under which the evidence was discovered were

[] ATTACHED ADDITIONAL SHEET(S)

7. Check all that apply:

[] (a) This evidence could not have been discovered or obtained by the exercise of diligence

before the expiration of 21 days following entry of the final order(s) of conviction or

adjudication of delinquency by the court; and/or

[] (b) The testing procedure was not available at the time of the conviction(s) or

adjudication(s) of delinquency became final in the circuit court.

8. The evidence upon which I base my claim is material and, when considered with all of

the other evidence in the record, will prove that no rational trier of fact would have found me

to be guilty or delinquent beyond a reasonable doubt of the charge(s) described above because

[] ATTACHED ADDITIONAL SHEET(S)

9. In support of this petition, I have attached the following documents:

[] ATTACHED ADDITIONAL SHEET(S)

10. I understand that this petition must contain all relevant allegations of facts that

are known to me at this time.

11. I understand that it must include all previous records, applications, petitions, and

appeals and their dispositions related to this/these conviction(s) or adjudication(s) of

delinquency, as well as a copy of any documents or evidence in support of the facts that I

assert above.

12. I understand that if this petition is not complete, this Court may dismiss

the petition or return the petition to me pending the completion of such form.

13. I understand that I am responsible for all statements contained in this

petition.

14. I understand that any knowingly or willfully made false statement is

grounds for prosecution and conviction of perjury as provided for in

Virginia Code § 18.2-434.

15. Counsel. Check the appropriate box.

[] I am being represented by an attorney on the filing of this petition.

My attorney's name and address are

[] I am not being represented by an attorney on the filing of this petition.

16. Exemption from filing fee. Check box below if claiming in forma pauperis

status and seeking to file this petition without payment of fees.

[] I claim in forma pauperis status and I request that this Court accept

this petition without the payment of filing fees. I affirm under oath that I

am eligible for in forma pauperis status. My assets amount to $____________

(which sum includes my institutional inmate account which has a balance of

$____________), and my liabilities amount to $____________.

17. Request for counsel. Check box below if claiming eligibility for court-appointed

counsel and requesting appointment of counsel.

[] I am requesting that the Court appoint counsel to represent me in this

action. I affirm under oath that I am unable to pay for an attorney to

represent me in this action, as set forth in item No. 16 above.

Based on the above, I petition this Court pursuant to the provisions of Chapter 19.3 of

Title 19.2 of the Code of Virginia for a Writ of Actual Innocence Based on Nonbiological

Evidence.

DATE SIGNATURE OF PETITIONER

Commonwealth/State of ________________________________________

[] City [] County of __________________________________

Subscribed and sworn to/affirmed before me on this date by the above-named

person.

DATE NOTARY PUBLIC

My commission expires: _______________

DATE SIGNATURE OF ATTORNEY (IF APPLICABLE)

VIRGINIA STATE BAR NUMBER

Pro se (self-represented) petitioners: You are required to send copies of the PETITION FOR A

WRIT OF ACTUAL INNOCENCE BASED ON NONBIOLOGICAL EVIDENCE and all attachments to the

Commonwealth's Attorney of the jurisdiction where the conviction(s) or adjudication(s) of

delinquency occurred and to the Attorney General of Virginia by certified mail. You must

complete the form entitled Court of Appeals Form CAV-104, CERTIFICATE OF MAILING -

PETITION FOR A WRIT OF ACTUAL INNOCENCE BASED ON NONBIOLOGICAL EVIDENCE.

Petitioners represented by counsel: You are required to serve copies of the PETITION FOR A

WRIT OF ACTUAL INNOCENCE BASED ON NONBIOLOGICAL EVIDENCE and all attachments on

the Commonwealth's Attorney of the jurisdiction where the conviction(s) or adjudication(s) of

delinquency occurred and on the Attorney General of Virginia. You must include the forms

entitled Court of Appeals Form CAV-103CA, ACCEPTANCE OF SERVICE OR RETURN OF

SERVICE BY THE COMMONWEALTH'S ATTORNEY - PETITION FOR A WRIT OF ACTUAL

INNOCENCE BASED ON NONBIOLOGICAL EVIDENCE and Court of Appeals Form CAV-103AG,

ACCEPTANCE OF SERVICE OR RETURN OF SERVICE BY THE ATTORNEY GENERAL - PETITION FOR

A WRIT OF ACTUAL INNOCENCE BASED ON NONBIOLOGICAL EVIDENCE.