Judicial Council of the _________________ Circuit COMPLAINT OF JUDICIAL MISCONDUCT OR DISABILITY To begin the complaint process, complete this form and prepare the brief statement of facts described in item 5 (below). The RULES FOR JUDICIAL-CONDUCT AND JUDICIAL-DISABILITY PROCEEDINGS, adopted by the Judicial Conference of the United States, contain information on what to include in a complaint (Rule 6), where to file a complaint (Rule 7), and other important matters. The rules are available in federal court clerks' offices, on individual federal courts' Web sites, and on www.uscourts.gov. Your complaint (this form and the statement of facts) should be typewritten and must be legible. For the number of copies to file, consult the local rules or clerk's office of the court in which your complaint is required to be filed. Enclose each copy of the complaint in an envelope marked "COMPLAINT OF MISCONDUCT" or "COMPLAINT OF DISABILITY" and submit it to the appropriate clerk of court. Do not put the name of any judge on the envelope. 1. Name of Complainant: Contact Address: Daytime telephone: ( ) 2. Name(s) of Judge(s): Court: 3. Does this complaint concern the behavior of the judge(s) in a particular lawsuit or lawsuits? [ ] Yes [ ] No If "yes," give the following information about each lawsuit: Court: Case Number: Docket number of any appeal to the Circuit: ___________________ Are (were) you a party or lawyer in the lawsuit? [ ] Party [ ] Lawyer [ ] Neither Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com If you are (were) a party and have (had) a lawyer, give the lawyer's name, address, and telephone number: 4. Have you filed any lawsuits against the judge? [ ] Yes [ ] No If "yes," give the following information about each such lawsuit: Court: Case Number: Present status of lawsuit: Name, address, and telephone number of your lawyer for the lawsuit against the judge: Court to which any appeal has been taken in the lawsuit against the judge: Docket number of the appeal: Present status of the appeal: 5. Brief Statement of Facts. Attach a brief statement of the specific facts on which the claim of judicial misconduct or disability is based. Include what happened, when and where it happened, and any information that would help an investigator check the facts. If the complaint alleges judicial disability, also include any additional facts that form the basis of that allegation. Declaration and signature: 6. I declare under penalty of perjury that the statements made in this complaint are true and correct to the best of my knowledge. (Signature)__________________________________ (Date)__________________ Page 2 of 2 American LegalNet, Inc. www.FormsWorkFlow.com