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TO: THE ________ COURT, COUNTY OF ________:

The petition of [Petitioner’s Name], for a Writ of Habeas
Corpus, respectfully shows to this Court and alleges:

1. I am imprisoned and restrained of my liberty at the
________ Jail of ________ County, and the officer or person by whom I am so
restrained is the Defendant above-named, the Warden of said Jail.

2. I have not been committed and am not detained by virtue
of any final judgment or decree, or any final order, mandate or process.

3. The cause or pretense of such imprisonment or
restraint, according to my best knowledge and belief, is a commitment issued by
the ________ Court, County of ________, based upon an indictment charging me
with the crime of ________, a copy of which commitment is annexed hereto, marked
“Exhibit A,” and made part hereof.

WHEREFORE, I pray that a Writ of Habeas Corpus issue,
directed to the Defendant above-named, or whosoever has custody of the
Petitioner before this Court, at a ________ Term, Part ________ thereof, to be
held in and for the County of ________, at the Courthouse, [Street Address,
City, State] on [date] at ________[a.m./p.m.], so that this Court may inquire
into the legality of my detention.

Dated: ________ ________[Signature]

[Name of Petitioner]