FORM 5

STATE OF SOUTH CAROLINA	)
)	IN THE COURT OF COMMON PLEAS
COUNTY OF	)
)
)
Full name and prison number (if any) of Applicant.	)
)
v.	)	APPLICATION FOR
)
State of South Carolina	)	POST-CONVICTION RELIEF
)

INSTRUCTIONS - READ CAREFULLY

In order for this application to receive consideration by the Court, it shall be in writing (legibly handwritten or typewritten), signed by the applicant and verified (notarized), and it shall set forth in concise form the answers to each applicable question. If necessary, applicant may furnish his answer to a particular question on the reverse side of the page or on an additional page. Applicant shall make clear to which question any such continued answer refers.

Since every application must be sworn under oath, any false statement of a material fact therein may serve as the basis of prosecution and conviction for perjury. Applicants should, therefore, exercise care to assure that all answers are true and correct.

If the application is taken in forma pauperis, it shall include an affidavit (attached at the back of the form) setting forth information which establishes that applicant will be unable to pay the fees and costs of the proceedings. When the application is completed, the original shall be mailed to the Clerk of Court for the County in which the applicant was convicted.

1.	Place of detention

2.	Name and location of Court which imposed sentence

3.	Name(s) of co-defendant(s) (if any)

4.	The indictment number or numbers (if known) upon which and the offenses for which sentence was imposed:

(a)

(b)

(c)

5.	The date upon which sentence was imposed and the terms of the sentence:

(a)

(b)

(c)

6.	Check whether a finding of guilty was made:

(a)	after a plea of guilty

(b)	after a plea of not guilty

(c)	after a plea of nolo contendere

7.	Did you appeal from the judgment of conviction or the imposition of sentence?

8.	If you answered “yes” to (7), list:

(a)	the name of each Court to which you appealed:

i.

ii.

iii.

(b)	the result in each such Court to which you appealed:

i.

ii.

iii.

(c)	the date of each such result:

i.

ii.

iii.

(d)	if known, citations of any written opinion or orders entered pursuant to such results:

i.

ii.

iii.

9.	If you answered “no” to (7), state your reasons for not so appealing:

(a)

(b)

(c)

10.	State concisely the grounds on which you base your allegation that you are being held in custody unlawfully:

(a)

(b)

(c)

11.	State concisely and in the same order the facts which support each of the grounds set out in (10):

(a)

(b)

(c)

12.	Prior to this application have you filed with respect to this conviction:

(a)	any petition in a State Court under South Carolina Law?

(b)	any petition in State or Federal Courts for habeas corpus or post-convictions relief?

(c)	any petition in the United States Supreme Court for certiorari other than petitions, if any, already specified in (8)?

(d)	any other petitions, motions or applications in this or any other Court?

13.	If you answered “yes” to any part of (12), list with respect to each petition, motion or application:

(a)	the specific nature thereof:

i.

ii.

iii.

iv.

(b)	the name and location of the Court in which each was filed:

i.

ii.

iii.

iv.

the disposition thereof:

i.

ii.

iii.

iv.

(d)	the date of each such disposition:

i.

ii.

iii.

iv.

(e)	if known, citations of any written opinions or orders entered pursuant to each such	disposition:

i.

ii.

iii.

iv.

14.	Has any ground set forth in (10) been previously presented to this or any other Court, State or Federal, in any petition, motion or application which you have filed?

15.	If you answered “yes” to (14) identify:

(a)	which grounds have been presented:

i.

ii.

iii.

(b)	the proceedings in which each ground was raised:

i.

ii.

iii.

16.	If any ground set forth in (10) has not previously been presented to any Court, State or Federal, set forth the ground and state concisely the reasons why such ground has not previously been presented:

(a)

(b)

(c)

17.	Were you represented by an attorney at any time during the course of:

(a)	your arraignment and plea?

(b)	your trial, if any?

(c)	your sentencing?

(d)	your appeal, if any, from the judgment of conviction or the imposition of sentence?

(e)	preparation, presentation or consideration of any petitions, motions or applications	with respect to this conviction, which you filed?

18.	If you answered “yes” to one or more parts of (17), list:

(a)	the name and address of each attorney who represented you:

i.

ii.

iii.

(b)	the proceedings at which each such attorney represented you:

i.

ii.

iii.

19.	State clearly the relief you seek in filing this application:

20.	Are you now under sentence from any other court that you have not challenged?

STATE OF SOUTH CAROLINA	)
)	VERIFICATION
County of	)

I, , being duly sworn upon my oath, depose and say that I have subscribed to the foregoing application; that I know the contents thereof; that it includes every ground known to me for vacating, setting aside or correcting the conviction and sentence attacked in this application; and that the matters and allegations therein set forth are true.

__________________________________________

SWORN to and subscribed before me this

day of	, 2	.

_______________________________________ (L.S.)

Notary Public

My Commission Expires:

APPLICATION TO PROCEED WITHOUT PAYMENT

OF COSTS AND AFFIDAVIT

IN SUPPORT THEREOF

I, , hereby apply for leave to proceed in this action without prepayment of fees or costs or security therefor. In support of my application I declare under penalty of perjury that the following facts are true:

(1)	I am the applicant in this action and I believe I am entitled to redress.

(2)	Because of my poverty I am unable to pay the costs of said proceeding or give	security thereof.

________________________________________

Applicant

SWORN or affirmed to and subscribed before me this

day of	, 2	.

__________________________________________

Notary Public

My Commission Expires:

Revised 3/2003

1

FORM 5

cyon

2005-02-17

S.C. Judicial Dept.