1.

Name and current address of person claiming to have been tortured:

2.

Name and current address of person signing this form (if different than No. 1 above):

3.

Details of claimant's felony conviction based upon allegedly tortured confession:

a.

Circuit Court:

b.

Year:

c.

Crimes of Conviction:

d.

Sentence:

e.

Case Number (if known):

4.

Details of alleged torture:

a.

Law enforcement agency:

b.

Dates:

c.

Names of persons committing alleged torture:

d.

Brief description of alleged torture:

5.

As a result of the torture described above, did you confess to the offense of which you were convicted?

  Yes

 No

6.

If you did confess, was that confession used against you to obtain the conviction?

  Yes

 No

7.

Names and current addresses of persons who could support your claim:

a. 

b.

c.

d.

e.

8.

Location of documentation supporting your claim:

Claimant or Person Signing on Claimant's Behalf

Date