Clerk of the Supreme Court, Court of Appeals, and Tax Court STATE OF INDIANA ROLL OF ATTORNEYS INFORMATION AFFIDAVIT OF INACTIVE STATUS (Please print or type all fields except for signature line) FULL NAME: BAR NUMBER: After having first been duly sworn upon my oath, I depose and say that: 1. 2. 3. 4. I am duly admitted to practice before the Indiana Supreme Court. I am not engaged in the practice of law in Indiana in any manner. I do not hold judicial office in the State of Indiana. I understand that my bar status established by this affidavit will remain effective until I initiate a change through Clerk of the Supreme Court. CHOOSE AN APPLICABLE CATEGORY: INACTIVE GOOD STANDING AFFIDAVIT A. I wish to place or retain my Indiana law license in inactive status. I am currently in active or inactive good standing. B. I acknowledge that by claiming Inactive Good Standing status, I will be responsible for paying a reduced annual registration fee in the amount set forth in Admis.Disc.R. 2(c). C. I understand that I have an obligation to notify the Clerk of the Supreme Court of any change of name or address within thirty (30) days of such change as required by Admis.Disc.R. 2. RETIREMENT AFFIDAVIT A. At the time of executing this Affidavit, my Indiana law license is in either active or inactive good standing. B. I am sixty-five (65) years of age or older. C. I understand that by claiming Retired Inactive status, I am exempt from the payment of any annual registration fee, and until I take steps to change my bar status to active or inactive good standing, I will not receive an annual registration fee notice from the Clerk of the Supreme Court. VERIFICATION I SWEAR OR AFFIRM, UNDER PENALTIES FOR PERJURY, THAT THE FOREGOING STATEMENTS ARE TRUE. SIGNATURE: DATE: BUSINESS INFORMATION: ADDRESS: CITY, STATE ZIP: PHONE NUMBER: FAX NUMBER: E-MAIL ADDRESS: RESIDENTIAL INFORMATION: ADDRESS: CITY, STATE ZIP: PHONE NUMBER: FAX NUMBER: E-MAIL ADDRESS: THIS FORM MAY NOT BE FAXED. AN ORIGINAL SIGNATURE MUST BE RECEIVED BY THE CLERK’S OFFICE. Clerk of the Supreme Courts Attn: Roll of Attorneys 402 West Washington Street, Room W062 Indianapolis, IN 46204 American LegalNet, Inc. www.FormsWorkflow.com