Informational Statement - Attorney Matters See 247 670.3 of the rules of this court for directions on the use of this form (22 NYCRR 670.3). Informational Statement - Attorney Matters Case Title: Set forth the title of the case as it appears on the notice of petition or order to show cause by which the matter is to be commenced. For Appellate Division Use In the Matter of an Attorney and Counselor at Law. Case Type Special Proceeding Other Filing Type Attorney Matter Agency Grievance Committee for: 2nd & 11th 9th 10th Judicial District(s) Committee on Character and Fitness for: 2nd, 10, & 11th 9th Judicial District(s) Attorney or Applicant Information Name Under Which Admitted or to be Admitted to Bar: Department of Admission: Date of Admission: Date of Birth: Roll of Attorneys: Volume No. Page No. Attorney Registration No.: Current Address: City: State: Zip: Telephone No.: Counsel for Attorney or Applicant Counsel/Firm Name: Address: City: State: Zip: Telephone No.: Issues Raised Admission to Practice - Character & Fitness Aiding and Abetting a Non-Lawyer in the Practice of Law Commingling Funds Conduct Adversely Reflecting on the Fitness to Practice Law Conduct Involving Moral Turpitude Conduct Prejudicial to the Administration of Justice Conflict of Interest - Overreaching Conversion Conviction of a Felony Conviction of Other Crime Conviction of a "Serious Crime" under 22 NYCRR 691.7 Dishonesty, Fraud, Deceit, or Misrepresentation Failure to Cooperate Failure to Keep Records Failure to Register or Re-Register Mental or Physical Incapacity Neglect Reciprocal Discipline Reinstatement - Character & Fitness Other (specify): Supreme Court of the State of New York Appellate Division : Second Judicial Department American LegalNet, Inc. www.FormsWorkFlow.com