Indiana Interest on Lawyer Trust Accounts (IOLTA) Exemption Form Attorney Name: ________________________________________________ Supreme Court Attorney Number: ________________________________ I certify that I am exempt from participation in the Interest on Lawyers’ Trust Accounts (IOLTA) Program for one or more of the following reasons (please check all that apply) ______ 1. I am not in the private practice of law, or my private practice of law does not involve Indiana client trust funds, or I do not have an office within the state of Indiana. ______ 2. I am a judge, attorney general, public defender, U.S. Attorney, prosecuting attorney, on duty with the armed services or employed by a local, state or federal government, a corporate counsel or teacher of law and am not otherwise engaged in the private practice of law. ______3. Participation in the IOLTA program would work an undue hardship on me and/or would be extremely impractical, based on the geographic distance between my principal office and the closest depository institution which is participating in the IOLTA program and/or other compelling and necessitous factors. If you have checked this line, please explain your situation. Attach additional pages as necessary. I certify that the information provided is accurate, to the best of my knowledge. Signature: ________________________________________ Date: ___________________________________________ Please fax this completed form back to the Indiana Bar Foundation at (317) 269-2420 or via e-mail at info@inbf.org. American LegalNet, Inc. www.USCourtForms.com