APPENDIX EAffidavit in Support of Application to Resign For Non-Disciplinary Reasons INSTRUCTIONSAn application pursuant to section 1240.22 (a) of these Rules to resign as an attorney andcounselor-at-law for non-disciplinary reasons shall comply with the following requirements: (1)The application shall be submitted in affidavit form, subscribed and sworn to before a notarypublic or other person authorized to administer an oath, and shall be worded and numbered as setforth below.(2)In completing the affidavit, the respondent should not omit inapplicable passages.(3)Place the moving papers in the following order:a.The attorney's form affidavit;b.The exhibits supporting that form affidavit; andc.Affidavits reflecting service of the application upon the Chief Attorney of theappropriate Committee and the Lawyers' Fund for Client Protection. American LegalNet, Inc. www.FormsWorkFlow.com FORM OF AFFIDAVITSupreme Court of the State of New YorkAppellate Division: Judicial DepartmentIn the Matter of the Application of [Attorney's Name], AFFIDAVIT IN SUPPORTOF APPLICATION TO RESIGN FOR NON-DISCIPLINARY REASONSfor an order removing the attorney's name from the roll ofattorneys and stating the non-disciplinary nature of theresignation.State of ) )ss.: County of ), being duly sworn, deposes and says that: 1.I hereby apply, pursuant to section 1240.22 (a) of the Uniform Rules for AttorneyDisciplinary Matters, to resign for non-disciplinary reasons as an attorney and counselor-at-lawlicensed to practice in the State of New York.2.My full name is . The name under which I was admitted tothe practice of law is . My name was changed on the Roll ofAttorneys and Counselors-at-Law to by reason of (marriage, divorceor annulment, or a court order legally changing the respondent's name). I have also been knownby the following names: .[Copies of all court orders changing my name are attached as exhibit hereto.] I was born onI currently reside at 5.All communications may be addressed to me at the office of my attorney, , , and I hereby authorize my attorney to accept and acknowledge receipt of any and alllegal documents or other notices on my behalf.-OR -All communications may be addressed to me personally at the following address:. American LegalNet, Inc. www.FormsWorkFlow.com I was admitted to the New York State Bar onDepartment, and my attorney registration number is .I have also been admitted to practice in the following courts or jurisdictions:. -OR -I attest that I have not been admitted to practice in any other courts or jurisdictions.8.I have been the subject of professional discipline in the following other courts orjurisdictions: [state the court or jurisdiction, the date, the nature of the discipline imposed,whether such discipline was public or private, and whether or not you have been reinstated topractice and are now in good standing in such court or jurisdiction].[A copy of each order or judgment imposing such discipline is attached as exhibit hereto.A copy of each order or judgment reinstating me to practice is attached as exhibit hereto.]-OR -I attest that I have not been the subject of professional discipline in this or any other court orjurisdiction.9.I am currently the subject of an attorney disciplinary complaint or proceeding in thefollowing courts or jurisdictions: [state the nature of the complaint or proceeding, the disciplinaryauthority before which it is pending, and the status thereof].-OR -I attest that I am not currently the subject of an attorney disciplinary complaint in this or anyother court or jurisdiction.10.Since the date of my admission to the New York State Bar, I have been arrested, chargedwith, indicted, convicted, tried, and/or entered a plea of guilty to the following felonies,misdemeanors, violations, and/or traffic infractions: [state the court, the offense charged, anddate and nature of disposition].[Certificates of conviction pertaining to the above are attached as exhibit hereto.]-OR -I attest that, since the date of my admission to the New York State Bar, I have not been arrested,charged with, indicted, convicted, tried, and/or entered a plea of guilty to any felonies,misdemeanors, violations, and/or traffic infractions. I am current in my attorney registration and in payment of attorney registration feespursuant to Rules of the Chief Administrator of the Courts (22 NYCRR) 247 118.1 [or, if notcurrent, state the length of any delinquency and the amount of arrears].The specific reasons for this application to resign from the Bar of the State of New Yorkare as follows: . WHEREFORE, I request that the Court accept my application to resign as an attorney andcounselor-at-law licensed to practice in the State of New York. American LegalNet, Inc. www.FormsWorkFlow.com Dated: [city or town, state] , 20 Subscribed to and sworn to before me this day of , 20 Notary Public American LegalNet, Inc. www.FormsWorkFlow.com