INDIANA COMMISSION ON JUDICIAL QUALIFICATIONS 30 South Meridian, Suite 500 Indianapolis, Indiana 46204 (317) 232-4706 COMPLAINT AGAINST JUDGE FROM: Complainant's Name Complainant's Address ____________________________________________ (please print) ____________________________________________ street _________________________________ __________ city state zip Complainant's Telephone ____________________ (home) _____________________ (work) Judge's Name: _____________________________________________________________ Name of Court: _____________________________________________________________ Cause Number of Case (if applicable): __________________________________________ Names and telephone numbers of all attorneys who represented you at any time in this case: Nature of Complaint (Please state in full detail the basis of your complaint against the judge. You may use the reverse side of this form, if necessary, additional paper, or any other form as long as the information is complete and the complaint is sworn to be true.) I affirm, under penalties of perjury that the foregoing representations are true. I understand that the Indiana Commission on Judicial Qualifications does not have authority to intervene on my behalf in any proceeding or to change any decision reached by a court. In filing this complaint, I agree to cooperate with the Commission and its agents and to testify, if asked, concerning the matters raised in my complaint. I understand that the judge will receive a copy of my complaint and that Indiana Supreme Court Admission and Discipline Rule 25 VIII C provides that I am immune from civil suit against me based on the content of my allegations of judicial misconduct, if made without malice, only to the extent those allegations are made to the Commission. Therefore, I am not immune from civil suit for any allegations I make public or which I communicate to any entity other than the Commission. (signed) ________________________________________ American LegalNet, Inc. www.FormsWorkFlow.com