[Rule 16.7]

No. [appellate court]

[Put name of appellate court that you want to hear your case.]


[Put your name here.], )


Petitioner. )

If there is not enough room on this form, use the back of these pages or use other paper. Fill out all of this form and other papers you are attaching before you sign this form in front of a notary.




(full name and address)

apply for relief from confinement. I am ___ am not ___ now in custody serving a sentence upon conviction of a crime. (If not serving a sentence upon conviction of a crime) I am now in custody because of the following type of court order: ______________________________________.

(identify type of order)

1. The court in which I was sentenced is _______________________.

2. I was convicted of the crime(s) of ___________________________


3. I was sentenced after trial ___, after plea of guilty ___ on

_______________________. The judge who imposed sentence was

(date of sentence)


(name of trial court judge)

4. My lawyer at trial court was _________________________________

(name and address if known; if none, write "none")


5. I did ___ did not ___ appeal from the decision of the trial court. (If the answer is that I did), I appealed to _________________.

(name of court or courts to which appeal was taken)

My lawyer on appeal was ________________________________.

(name and address if known; if none, write "none")

The decision of the appellate court was ___ was not ___ published. (If the answer is that it was published, and I have this information), the decision is published in _____________________________________________________

(volume number, Washington Appellate Reports or


Washington Reports, and page number)

6. Since my conviction I have ___ have not ___ asked a court for some relief from my sentence other than I have already written above. (If the answer is that I have asked), the court I asked was __________


(name of court or courts in which relief was sought)

Relief was denied on _____________________________________.

(date of decision or, if more than one, dates of all decisions)

7. (If I have answered in question 6 that I did ask for relief), the name of my lawyer in the proceeding mentioned in my answer to question 6 was ______________________________________________________.

(name and address if known; if none, write "none")

8. If the answers to the above questions do not really tell about the proceedings and the courts, judges and attorneys involved in your case, tell about it here: _________________________________________________.


(If I claim more than one reason for relief from confinement, I attach sheets for each reason separately, in the same way as the first one. The attached sheets should be numbered "First Ground", "Second Ground", "Third Ground", etc.). I claim that I have ______ (number) reason(s) for this court to grant me relief from the conviction and sentence described in Part A.

_____________________ Ground

(First, Second, etc.)

1. I should be given a new trial or released from confinement because (Here state legal reasons why you think there was some error made in your case which gives you the right to a new trial or release from confinement.): ___________________________________________.

2. The following facts are important when considering my case (After each fact statement, put the name of the person or persons who know the fact and will support your statement of the fact. If the fact is already in the record of your case, indicate that, also.): ____________________________________________________.

3. The following reported court decisions (include citations if possible) in cases similar to mine show the error I believe happened in my case (If none are known, state "None known".): ____________________


4. The following statutes and constitutional provisions should be considered by the court (If none are known, state "None known".):


5. This petition is the best way I know to get the relief I want, and no other way will work as well because ___________________



If you cannot afford to pay the filing fee or cannot afford to pay an attorney to help you, fill this out. If you have enough money for these things, do not fill out this part of the form.

1. I do ___ do not ___ ask the court to file this without making me pay the filing fee because I am so poor I cannot pay the fee.

2. I have a spendable balance of $______ in my prison or institution account.

3. I do ___ do not ___ ask the court to appoint a lawyer for me because I am so poor I cannot afford to pay a lawyer.

4. I am ___ am not ___ employed. My salary or wages amount to $______ a month. My employer is __________


(name and address)

5. During the past 12 months I did ___ did not ___ get any money from a business, profession or other form of self‑employment. (If I did, it was ______________________ and the total income I got was $______.)

(kind of self‑employment)

6. During the past 12 months, I

did did not get any rent payments. If so, the total amount I got was $__________.

___ ___ get any interest. If so, the total amount I got was $__________.

___ ___ get any dividends. If so, the total amount I got was $__________.

___ ___ get any other money. If so, the amount of money I got was $__________.

7. ___ ___ have any cash except as said in answer 2. If so, the total amount of cash I have is $__________.

___ ___ have any savings accounts or checking accounts. If so, the amount in all accounts is $__________.

___ ___ own stocks, bonds, or notes. If so, their total value is $__________.

8. List all real estate and other property or things of value which belong to you or in which you have an interest. Tell what each item of property is worth and how much you owe on it. Do not list household furniture and furnishings and clothing which you or your family need.

Items Value

_____________________________________9. I am ___ am not ___ married. If I am married, my wife or husband's name and address is ________________________________________


10. All of the persons who need me to support them are listed here.

Name and Address Relationship Age


11. All the bills I owe are listed here.

Name of creditor Address Amount

you owe money to



I want this court to:

___ vacate my conviction and give me a new trial

___ vacate my conviction and dismiss the criminal charges against me without a new trial

___ other (specify) ________________________________




) ss.

County of _________________ )

After being first duly sworn, on oath, I depose and say: That I am the petitioner, that I have read the petition, know its contents, and I believe the petition is true.


[sign here]

SUBSCRIBED AND SWORN to before me this ___ day of__________.


Notary Public in and for the State

of Washington, residing at ________

If a notary is not available, explain why none is available and indicate who can be contacted to help you find a notary: _____________



Then sign below:

I declare that I have examined this petition and to the best of my knowledge and belief it is true and correct.



[sign here]

Amended effective November 21, 2006.