AFFIDAVIT OF ATTORNEY SEEKING PERMISSION TO APPEAR PRO HAC VICE JD-CL-143 New 1-17 P.B. 2-16 STATE OF CONNECTICUT SUPERIOR COURT www.jud.ct.gov Instructions Complete Affidavit and deliver to Connecticut attorney making application on your behalf. Court Information: Judicial district Address of court If Application is for a Court Case: Name of case Docket number If Application is for a proceeding before a State or Municipal Agency, Commission, Board, or Tribunal: Name of out-of-state attorney In Re Pro Hac Vice Application Name of agency, commission, board or tribunal Case number Affidavit: I, I am over the age of 18 and believe in the duties and obligations of an oath. I make this Affidavit in support of an Application to appear pro hac vice before (name of court, agency, commission, board, or tribunal) for a proceeding regarding (client name) I have a law office located at: I am a member in good standing of the bar(s) of: , being duly sworn, do depose and say: I certify that: There is no grievance pending against me in any jurisdiction, nor have I ever been reprimanded, suspended, placed on inactive status, disbarred or otherwise disciplined, nor have I ever resigned from the practice of law in any jurisdiction. There is a grievance pending against me, or I have been disciplined as follows (explain): I have paid the Client Security Fund Fee due for June of I hereby designate the Chief Clerk for the Judicial District of upon whom process and service of notice may be served. , the calendar year in which the application is made. as my agent I agree to register with the Statewide Grievance Committee in accordance with the provisions of Chapter 2 of the Connecticut Rules of Practice while appearing in the matter in this State and for two years after the completion of the matter in which I have appeared pro hac vice and will notify the Statewide Grievance Committee of the expiration of the two year period. (Page 1 of 2 ) American LegalNet, Inc. www.FormsWorkFlow.com I have appeared times pro hac vice in the superior court or in any other proceedings in the State of Connecticut since I first appeared pro hac vice in this state; the case names and docket numbers of those proceedings are: I have previously been assigned Juris Number as a pro hac vice attorney in Connecticut. I understand that, unless excused by the judicial authority, Connecticut Attorney , who submitted the Application on my behalf, must be present at all proceedings, including depositions in a proceeding, and must sign all pleadings, briefs and other papers filed with the court, agency, commission, board, or tribunal named above, and assume full responsibility for them and for the conduct of the cause or proceeding and of this Affiant. Good Cause exists to permit me to represent the client named in this Affidavit in the proceeding before the above named court, agency, commission, board, or tribunal. (Describe the facts or circumstances affecting the personal or financial welfare of the client that establish "good cause"): Signed (Out-of-State Attorney/Affiant) Print name Signed (Commissioner of Superior Court/Notary Public) Date signed Date signed Subscribed and sworn to before me: The Judicial Branch of the State of Connecticut complies with the Americans with Disabilities Act (ADA). If you need a reasonable accommodation in accordance with the ADA, contact a court clerk or an ADA contact person listed at www.jud.ct.gov/ADA. ADA NOTICE (Page 2 of 2 ) American LegalNet, Inc. www.FormsWorkFlow.com