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Name 

 
Address 

 
City, State, Zip 

 
Phone 

 
Email  
 

 

v. 

 
 
 

 

 

In the District Court of Utah 

__________ Judicial District ________________ County 

Court Address ______________________________________________________ 

_____________________________________ 
Petitioner 

Petition for Relief Under the Post-
Conviction Remedies Act 
Utah Code Section 78B-9-101 et seq. 
Utah Rule of Civil Procedure 65C 

_______________________________ 
Case Number 

_____________________________________ 
Respondent 

_______________________________ 
Judge 

Notice to the Petitioner:  

Before completing this form, please read it carefully. If you have any questions, contact 
an attorney. Court clerks are not allowed to give legal advice. Attach additional sheets 
of paper as necessary to complete your answers. Show the question number from this 
form on the additional sheet of paper. 

I. 

Name of Respondent (check one) 

[  ]  Conviction of Felony 
[  ]  Conviction of Misdemeanor or Ordinance  County of: __________________ 
[  ]  Conviction of Misdemeanor or Ordinance  Municipality of: ______________ 

State of Utah 

2009 / Revised June 13, 2022 

Petition for Relief Under the Post-Conviction Remedies Act 

Page 1 of 10 

 

 

II. 

1. 

 

 

 

2. 

3. 

Identification of Current and Related Cases 

(a) 

Name of court that entered the judgment being challenged: 

 

___________________________________________________________ 

(b) 

Location of court: _____________________________________________ 

(c) 

Case number: ____________________________ 

Date of judgment being challenged: ____________________________ 

Sentence: 

6. 

If you entered a plea of guilty to some counts, and a not guilty plea to other 
counts, give your plea to each count: 

7. 

If you plead not guilty or not guilty by reason of insanity, was the trial before a  

2009 / Revised June 13, 2022 

Petition for Relief Under the Post-Conviction Remedies Act 

Page 2 of 10 

 

 

   

     

     

4. 

Nature of offense involved (all counts): 

5.  What was your plea? (check one) 

[  ]  Not guilty 

[  ]  Guilty 

[  ]  No contest 

[  ]  Guilty and mentally ill 

[  ]  Not guilty by reason of insanity 

 

[  ] Jury    [  ]  Judge 

8. 

Did you testify at the trial? 

[  ] Yes    [  ]  No 

9. 

Did you appeal from the conviction or sentence? 

[  ] Yes    [  ]  No 

10. 

If your answer is “yes,” provide the following information: 

(a) 

Name of Appellate Court: ______________________________________ 

(b) 

Case Number: ____________________________ 

(c) 

Result: 

(d) 

Date of result or citation of opinion: _______________________________ 

(e)  Grounds raised: 

(f) 

Did you seek further review of this appeal? 

[  ] Yes    [  ]  No 

(g) 

If your answer is “yes,” provide the following information: 

(1) 

Name of Reviewing Court: ________________________________ 

(2) 

Case number: ____________________________ 

(3) 

Result: 

(4) 

Date of result or citation of opinion: _________________________ 

2009 / Revised June 13, 2022 

Petition for Relief Under the Post-Conviction Remedies Act 

Page 3 of 10 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

     

 

 

 

 

(5)  Grounds raised: 

 

     

 

     

     

11. 

If you did not appeal from your conviction or sentence, why not? 

12. 

(a)  Other than your direct appeal from your conviction or sentence, have you 
filed any petitions, applications, or motions with respect to this conviction 
or sentence in any court, state or federal? 

[  ] Yes    [  ]  No 

(b) 

If your answer is “yes,” provide the following information: 

(1) 

Name of Court: _________________________________________ 

(2) 

Case number: ____________________________ 

(3) 

Result: 

(4) 

Date of result or citation of opinion: _________________________ 

(5)  Grounds raised: 

(c) 

Did you receive an evidentiary hearing on your petition, application or 
motion? 

[  ] Yes    [  ]  No 

2009 / Revised June 13, 2022 

Petition for Relief Under the Post-Conviction Remedies Act 

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(d) 

Did you appeal the decision on your petition, application, or motion? 

[  ] Yes    [  ]  No 

(e) 

If your answer is “yes,” provide the following information: 

(1) 

Name of Court: _________________________________________ 

(2) 

Case number: ____________________________ 

(3) 

Result: 

(4) 

Date of result or citation of opinion: _________________________ 

(5)  Grounds raised: 

13. 

(a)  Other than the case described in question 12, have you filed any further 
petitions, applications or motions with respect to this conviction or 
sentence in any court, state or federal? 

[  ] Yes    [  ]  No 

(b) 

If your answer is “yes,” provide the following information: 

(1) 

Name of Court: _________________________________________ 

(2) 

Case number: ____________________________ 

(3) 

Result: 

(4) 

Date of result or citation of opinion: _________________________ 

(5)  Grounds raised: 

2009 / Revised June 13, 2022 

Petition for Relief Under the Post-Conviction Remedies Act 

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(c) 

Did you receive an evidentiary hearing on your petition, application or 
motion? 

(d) 

Did you appeal the decision on your petition, application, or motion? 

(e) 

If your answer is “yes,” provide the following information: 

(1) 

Name of Court: _________________________________________ 

(2) 

Case number: ____________________________ 

[  ] Yes    [  ]  No 

[  ] Yes    [  ]  No 

(3) 

Result: 

(4) 

Date of result or citation of opinion: _________________________ 

(5)  Grounds raised: 

14. 

(a) 

Do you have any petition, appeal, or motion now pending in any court, 
state or federal, relating to the judgment being challenged? 

[  ] Yes    [  ]  No 

(b) 

If your answer is “yes,” provide the following information: 

(1) 

Name of Court: _________________________________________ 

(2) 

Case number: ____________________________ 

(3) 

Nature of Proceeding: 

2009 / Revised June 13, 2022 

Petition for Relief Under the Post-Conviction Remedies Act 

Page 6 of 10 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

III. 

Grounds for Relief 

Notice to the Petitioner: You may be barred from presenting additional grounds in a 
future post-conviction petition if you fail to present any grounds that you could present 
here but do not. 

The following is a list of the most frequently raised grounds for relief in post-conviction 
proceedings. Each statement preceded by a letter constitutes a separate ground for 
possible relief. You should raise in this petition any of these grounds that apply and any 
other grounds not listed that you may have available. 

Do not merely check the grounds listed. If you believe any of these grounds apply to 
you, you must allege facts. The petition will be returned to you if you merely check a 
ground and fail to list necessary facts or attach supporting documentation. 

(a) 

Conviction or sentence obtained by plea of guilty that was unlawfully 
induced or not made voluntarily with understanding of the nature of the 
charge and the consequences of the plea. 

(b)   Conviction or sentence obtained by use of coerced confession. 

(c)   Conviction or sentence obtained by use of evidence gained pursuant to an 

unconstitutional search and seizure. 

(d)   Conviction or sentence obtained by use of evidence obtained pursuant to 

(e)   Conviction or sentence obtained by a violation of the privilege against self-

an unlawful arrest. 

incrimination. 

(f)  

Conviction or sentence obtained by the unconstitutional failure of the 
prosecution to disclose to the defendant evidence favorable to the 
defendant. 

(g)   Conviction or sentence obtained by a violation of the protection against 

double jeopardy. 

(h)   Conviction or sentence obtained by action of a grand or petit jury that was 

unconstitutionally selected and impaneled. 

Denial of effective assistance of counsel. 

Conviction or sentence under an unconstitutional statute or constitutionally 
protected conduct. 

The prosecutor knowingly failed to correct false testimony at trial or at 
sentencing, and there is a reasonable likelihood the false testimony could 
have affected the judgment of the fact finder.  

(i)  

(j)  

(k) 

2009 / Revised June 13, 2022 

Petition for Relief Under the Post-Conviction Remedies Act 

Page 7 of 10 

 

 

     

     

     

   

 

 

15.   State concisely every ground on which you claim you are entitled to post-

conviction relief. Summarize briefly the facts supporting each ground. If 
necessary, you may attach additional pages stating additional grounds and facts 
supporting same. 

 

(a)  Ground One: ________________________________________________ 

Supporting facts for Ground One (state briefly without citing law or making 
argument): 

 

(b)  Ground Two: ________________________________________________ 

Supporting facts for Ground Two (state briefly without citing law or making 
argument): 

(c) 

Ground Three: 
________________________________________________ 

Supporting facts for Ground Three (state briefly without citing law or making 
argument): 

 

(d)  Ground Four: ________________________________________________ 

Supporting facts for Ground Four (state briefly without citing law or making 
argument): 

2009 / Revised June 13, 2022 

Petition for Relief Under the Post-Conviction Remedies Act 

Page 8 of 10 

 

 

 

 

 

 

 

     

16. 

If any of the grounds listed above were not previously presented in any other 
court, state or federal, state briefly which grounds were not presented and your 
reasons for not presenting them: 

17.  Give the name and address, if known, of each attorney who represented you in 

the following stages of the judgment being challenged: 

(a) 

Preliminary hearing: __________________________________________ 

(b) 

Arraignment and plea: ________________________________________ 

(c) 

Trial: ______________________________________________________ 

(d) 

Sentencing: _________________________________________________ 

(e) 

Appeal: ____________________________________________________ 

(f) 

Post-conviction proceeding: ____________________________________ 

(g) 

Appeal from post-conviction proceeding: __________________________ 

18. 

(a) 

Do you have any future sentence to serve after you complete the 
sentence imposed by the judgment being challenged? 

[  ] Yes    [  ]  No 

(b) 

If your answer is “yes,” give the following information: 

(1) 

Name of Court: _________________________________________ 

 

 

(2) 

Location: ______________________________________________ 

(3) 

Case number: ____________________________ 

IV. Required Attachments 

Notice to the Petitioner: If you do not attach the required copies or provide an 
explanation why you cannot provide them, this petition will not be filed and will be 

2009 / Revised June 13, 2022 

Petition for Relief Under the Post-Conviction Remedies Act 

Page 9 of 10 

 

 

 

 

 

 

 

 

 

 

returned to you. You may then lose your right to file a petition if the statute of limitations 
expires before you file another petition. 

19.  Attach a copy of the following documents to this petition or provide an 

explanation why you cannot provide the copies. 

(a) 

(b) 

(c) 

(d) 

(e) 

(f) 

(g) 
 

The judgment and commitment being challenged. 

Any decision issued by an appellate court from the direct appeal. 

Any previously filed petition for post-conviction relief, and any decision 
issued as a result. 

Affidavits, documents, or other evidence that support your claim.  

A certificate from the Inmate Accounting Office if you are asking the court 
to waive your filing fee. 

Memorandum of Points and Authorities. 

A Declaration of Financial Status (Criminal) if you are asking for a court-
appointed lawyer.  

20. 

[  ] 

I ask the court to appoint a lawyer to represent me in this case. I am filing a 
Declaration of Financial Status (Criminal) with this petition.  

V.  Petitioner’s Signature 

I declare under criminal penalty under the law of Utah that everything stated in this document is true. 

Signed at ______________________________________________________ (city, and state or country). 

VI. Certification of Attorney (If the petitioner is represented by an attorney) 

I certify that I am the attorney for the petitioner, and that this petition complies with Rule 
11, Utah Rules of Civil Procedure. 

Signature ► 

Printed Name 

Signature ► 

Printed Name 

 

 

 

 

 

 

 

 

 

 

 
Date 

 
Date 

2009 / Revised June 13, 2022 

Petition for Relief Under the Post-Conviction Remedies Act 

Page 10 of 10