E-SERVICES ATTORNEY ADVERTISING ELECTRONIC FILING EXEMPTION REQUEST JD-GC-19 Rev. 10-17P.B. 247 2-28ASTATE OF CONNECTICUT STATEWIDE GRIEVANCE COMMITTEE JUDICIAL BRANCH www.jud.ct.govInstructions 1.Type or print clearly.2.File this form with the Statewide Grievance Committee at the below address prior to the firstdissemination of the advertisement that must be filed pursuant to section 2-28A of the Practice Book.A separate request must be filed for each advertisement.3.Each attorney who is responsible for the advertisement that must be filed pursuant to section 2-28A ofthe Practice Book must establish good cause for the granting of this request and must sign this form.4.Keep a copy of this form for your records.To: Statewide Grievance Committee, 287 Main St., Second Floor, East Hartford, CT 06118-1885 (Tel. 860 568-5157)The undersigned attorney(s) request exemption from the requirement that his/her/their attorney advertisement be filed electronically through Judicial Branch E-Services pursuant to section 2-28A of the Practice Book for the following reason(s): Granted.(Enclosed with this order is a paper copy of the attorney advertising filing form. This form must accompany the filed advertisement.)Denied. (The advertisement must be filed electronically through Judicial Branch E-Services.) For Statewide Grievance Committee Use Only 227 Do Not Write Below This Line Signed (Statewide/Assistant Bar Counsel) Date signed File dateThe Statewide Grievance Committee has considered this request and it is hereby: Name of AttorneyFrom: The below-named attorney(s): Address of Attorney Individual Juris number Telephone numberCertification And SignaturesEach attorney making this request must sign this form (Attach additional sheets as needed) Signature of Attorney Print or type name Date signed By signing below, I/we hereby certify that each attorney responsible for the advertisement that must be filed with the Statewide Grievance Committee pursuant to section 2-28A of the Practice Book has good cause to make this request. ADA NOTICE 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. American LegalNet, Inc. www.FormsWorkFlow.com