____________________ Plaintiff Case No.________________ vs. _____________________ Defendant VERIFIED STATEMENT PURSUANT TO RULE 1-3.11, RULES REGULATING THE FLORIDA BAR Comes now____________________________________________________, Movant herein, and respectfully represents the following: 1. Movant is an attorney and a member of the law firm of (or practices law under the name of) ___________________________________________________________, with offices at ________________________________________________________, __________________, (Street Address) (City) ________________________, __________________, ______________, __________________. (County) (State) (Zip Code) (Telephone) 2. Movant has been retained personally or as a member of the above named law firm on ___________________________ by ________________________________________________ (Date Representation Commenced) (Name of Party or Parties) ________________________________________________________(If the name of party or parties is confidential pursuant to an order, rule, or agreement of the parties, this information does not need to be provided and only the date on which the representation commenced must be disclosed), to provide legal representation in connection with the above-styled arbitration now pending in the State of Florida. 3. Movant is an active member in good standing and currently eligible to practice law in the following jurisdiction(s): (attach additional sheet if necessary) _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ 4. There are no disciplinary proceedings pending against Movant, except as provided below (give jurisdiction of disciplinary action, date of disciplinary action, nature of the violation and the sanction, if any, imposed): (attach additional sheet if necessary) _________________________________________________________________________ American LegalNet, Inc. www.USCourtForms.com _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ 5. Within the past five (5) years, Movant has not been subject to any disciplinary proceedings, except as provided below (give jurisdiction of disciplinary action, date of disciplinary action, nature of the violation and the sanction, if any, imposed): (attach additional sheet if necessary) _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ 6. Movant is not disbarred or suspended from practice in any jurisdiction. 7. Movant is not a Florida resident. 8. Movant is not a member of The Florida Bar but ineligible to practice law. 9. Movant has not previously been disciplined or held in contempt by reason of misconduct committed while engaged in representation pursuant to Rule 1-3.11 of the Rules Regulating The Florida Bar, except as provided below (give date of disciplinary action or contempt, reasons therefor, and court imposing contempt): (attach additional sheet if necessary) _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ 10. Movant has appeared as counsel in Florida arbitrations during the past five (5) years in the following matters: (attach additional sheet if necessary)(If the case name and case number are confidential pursuant to an order, rule, or agreement of the parties, this information does not need to be provided and only the dates of prior proceedings must be disclosed) Date of Arbitration Proceeding Case Name Case Number _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ American LegalNet, Inc. www.USCourtForms.com 11. Movant has read the applicable provisions of Rules 1-3.11 and 4-5.5 of the Rules Regulating The Florida Bar and certifies that this verified statement complies with Rule 1-3.11. 12. Movant agrees to comply with the provisions of the Florida Rules of Professional Conduct and consents to the jurisdiction of the courts and the Bar of the State of Florida. WHEREFORE, Movant respectfully files this verified statement with The Florida Bar to appear in this cause only. DATED this ___________ day of __________________________________, 20____. ___________________________________ Movant ______________________________ Social Security Number (This information does not need to be supplied to opposing counsel) STATE OF ______________________ COUNTY OF ______________________ I, ________________________________, do hereby swear or affirm under penalty of perjury that I am the Movant in the above-styled matter; that I have read the foregoing Statement and know the contents thereof, and the contents are true of my own knowledge and belief. ________________________________ Movant/Affiant The foregoing instrument was acknowledged before me this ___ day of _____________, 20__, by __________________________ who is personally known to me or who has produced _____________________ as identification and who did take an oath. _____ day of ___________, 20__. American LegalNet, Inc. www.USCourtForms.com _______________________________Notary Public Notary Public (Signature) _______________________________ (Printed or Typed Name) Commission Number:_____________ My commission expires: CERTIFICATE OF SERVICE I HEREBY CERTIFY that a true and correct copy of the foregoing statement was furnished by U.S. mail to PHV Admissions, The Florida Bar, 651 East Jefferson Street, Tallahassee, Florida 32399-2333 accompanied by payment of the $250.00 filing fee made payable to The Florida Bar and to ______________________________________________________________________________ ______________________________________________________________________________ (Name and Address of All Counsel of Record and of Parties Not Represented by Counsel)(If opposing counsel is not known at the time the verified statement is filed with The Florida Bar, the non-Florida lawyer shall serve a copy of the verified statement on opposing counsel within 10 days of learning the identity of opposing counsel) this __________ day of ______________________________, 20____. _______________________________ Movant American LegalNet, Inc. www.USCourtForms.com