B-9010-2 (rev 5/22/12) UNITED STATES BANKRUPTCY COURT Southern District of Indiana (Insert Case or Adversary Proceeding Caption here.) AFFIDAVIT IN SUPPORT OF MOTION TO APPEAR PRO HAC VICE (Required if applicant is not admitted in the State of Indiana) (Name of applicant), being first duly sworn upon (his/her) oath, states as follows: I am a practicing attorney, duly licensed to practice, and currently in good standing in: Court(s) Example: Northern District of Indiana Date(s) of Admission (month/year) Example: October 2005 My license has never been suspended nor revoked, and I am not currently subject to any disciplinary action with respect to the practice of law. I declare under penalty of perjury that these representations are true and correct. /s/ Name of Applicant Name of Applicant (required signature block) 1 American LegalNet, Inc. www.FormsWorkFlow.com B-9010-2 (rev 5/22/12) STATE OF [name of state] COUNTY OF [name of county] ) ) ) Before me, a notary public in and for said county and state, personally appeared (name of applicant), and being first duly sworn upon (his/her) oath, says that the facts alleged in the above Affidavit are true. Signed and sealed: _________________(date). ____________________________ Notary Public My Commission Expires: _____________________ 2 American LegalNet, Inc. www.FormsWorkFlow.com