APPENDIX B
POST-CONVICTION HABEAS CORPUS FORM
APPLICATION TO PROCEED IN FORMA PAUPERIS
AND AFFIDAVIT
STATE OF WEST VIRGINIA
County
Name Prisoner No. Case No.
Place of Confinement
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.
— — —
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 Yes No
b. Rent payments, interest or dividends Yes No
c. Pensions, annuities or life insurance payments Yes No
d. Disability or workers compensation payments Yes No
e. Gifts or inheritances Yes No
f. Any other sources Yes 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.
