, , , CaseNo. , . Plaintiffvs.Defendant VERIFIED STATEMENT PURSUANT TO 002RULE 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 thename of) with offices at,(Street Address) (City) , (County) (State) (Zip Code) (Telephone Number) 2.Movant has been retained personally or as a member of the above named law firmonby (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 practicelaw in the following jurisdiction(s): Include attorney or bar number(s): (attach additional sheet if necessary) JURISDICTION ATTORNEY/BAR NUMBER American LegalNet, Inc. www.FormsWorkFlow.com 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) 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 (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.): (attach additional sheet if necessary) American LegalNet, Inc. www.FormsWorkFlow.com . City, State Zip DATE OF ARBITRATION CASE NAME CASE NUMBER PR OC EEDI NG 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, 20Movant Street Address 1 Street Address 2 Movant222s Email American LegalNet, Inc. www.FormsWorkFlow.com , , w , . da 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 , 20known to me or who has producedand who did take an oath. byho is personally as identification y of 20Notary Public Notary Public (Signature) (Printed or Typed Name) Commission NumberMy 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 (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.FormsWorkFlow.com