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PETITIONER’S INFORMATION

Petitioner‘s printed name;

 

State- bar number, if applicablc:

 

Address:

 

 

 

Telephone:

 

Fax:

 

INMATE’S DECLARATION

1, jé}0 "\ 230 0

, am the petitioner (circle one) and

 

being presently incarcerated in 0~/ Y/ 0 7></ {j}(/v¢n!¢n [/{l/`/’) , declare under penalty of

peijury that, according to my belief, the facts stated in the above application are true and correct.

Signedon_g/Wmé€r' 47 ,20 /L/.

%ature Wetitioner (circle one)

 

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