UNITED STATES DISTRICT COURT DISTRICT OF CONNECTICUT 141 CHURCH STREET NEW HAVEN, CONNECTICUT 06510 (203) 773-2140 DINAH MILTON KINNEY ROBERTA D. TABORA CHIEF DEPUTY CLERK CJA PANEL ATTORNEY DATA INFORMATION SHEET PLEASE COMPLETE AND RETURN THIS SHEET TO LORI INFERRERA, DIVISION MANAGER, BY REGULAR M AIL TO 141 CHURCH STREET, NEW HAVEN, CT 06510, BY FAX (203-773-2334), OR BY SCANNING INTO PDF FORM AT AND EM AILING TO lori_inferrera@ ctd.uscourts.gov SOCIAL SECURITY NUMBER [required for any CJA payments]: This number must be supplied, even if your firm receives the payments! NAME AND MAILING ADDRESS (all fields are required to be completed): Last name, first name, middle initial or middle name Street address and/or P.O. Box City, state, zip code Email Address - REQUIRED! TELEPHONE NUMBER: Area code/telephone INITIAL BELOW YOUR CHOICE OF HOW PAYMENTS SHOULD BE REPORTED TO IRS: 1. 2. Under my social security number and name, as indicated above To the law firm with which I am affiliated. The law firm’s Taxpayer Identification Number, Name and Address are: Taxpayer Identification Number of Law Firm This number must be supplied if you selected option #2 above! Name of Law Firm Street Address of Law Firm City, State, Zip Signature of CJA Panel Attorney Date American LegalNet, Inc. www.FormsWorkflow.com APRIL 21, 2008