APPENDIX AAffidavit in Support of Application to Resign While Proceeding or Investigation is Pending INSTRUCTIONSAn application pursuant to section 1240.10 of these Rules to resign as an attorney andcounselor-at-law while a proceeding or investigation is pending shall comply with the followingrequirements: (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)The affidavit shall bear the caption and the docket number, if any, of the proceeding pendingbefore the Court. If no proceeding is pending, the caption shall denominate the Committeeconducting the investigation as the petitioner, and the subject of the investigation as therespondent.(3)In completing the affidavit, the respondent should not omit any passages.(4)Place the moving papers in the following order:a.The respondent's form affidavit;b.The exhibits supporting that form affidavit; andc.An affidavit reflecting service upon the Chief Attorney of the appropriate Committee. American LegalNet, Inc. www.FormsWorkFlow.com FORM OF AFFIDAVITSupreme Court of the State of New YorkAppellate Division: Judicial Department AFFIDAVIT IN SUPPORT OF APPLICATION TO RESIGN WHILE PROCEEDING OR INVESTIGATION IS PENDINGState of ) )ss.: County of ), being duly sworn, deposes and says that: I hereby apply, pursuant to section 1240.10 of the Uniform Rules for AttorneyDisciplinary Matters, to resign as an attorney and counselor-at-law licensed to practice in theState of New York.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 on [date] in [city, state, country]I currently reside at [street, town or city, state, and zip code]All communications may be addressed to me at the office of my attorney, [name],at[address], and I hereby authorize my attorney toaccept 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:. 6.I was admitted to the New York State Bar on by the JudicialDepartment, and my attorney registration number is . American LegalNet, Inc. www.FormsWorkFlow.com 7.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 am the subject of disciplinary charges pending before this Court in this proceeding, asset forth in the petition dated . I acknowledge that the charges include at least thefollowing acts of professional misconduct: .-OR -I am currently the subject of an investigation conducted by theinvolving allegations of professional misconduct on my part. I acknowledge that the allegationsinclude at least the following acts of professional misconduct:. 9.I attest that I cannot successfully defend against the based uponthe facts and circumstances of my professional conduct as described herein.10.My resignation is freely and voluntarily rendered, without coercion or duress by anyone,and with full awareness of the consequences, including that the Court's acceptance and approvalshall result in the entry of an order of disbarment striking my name from the roll of attorneys andcounselors-at-law.11.I hereby consent to the entry of an order by the Court, pursuant to Judiciary Law 247 90 (6-a), directing (1) that I make monetary restitution to the following persons in the amountsindicated: [state the name of each person whose money or property was willfully misappropriatedor misapplied, and specify the value of such money or property], and (2) that I reimburse the I attest that the willfully misappropriated or misapplied money or property in the practice of law.12.This resignation is submitted subject to any future application that may be made by aCommittee to any Department of the Appellate Division for an order, pursuant to Judiciary Law24790 (6-a), directing that I make restitution or reimburse the Lawyers' Fund for Client Protection,and I consent to the continuing jurisdiction of the Appellate Division to make such an order. 13.I acknowledge and agree that pending issuance of an order accepting this resignation, Ishall not undertake to represent any new clients or accept any retainers for future legal services tobe rendered and that there will be no transactional activity in any fiduciary account to which Ihave access, other than for payment of funds held therein on behalf of clients or others entitled toreceive them.14.I understand further that, in the event the Court accepts my resignation, the order resultingfrom this application and the records and documents filed in relation to the aforementioned , including this affidavit, shall be deemed public records pursuant to Lawyers' Fund for Client Protection the sum dollar amount]. American LegalNet, Inc. www.FormsWorkFlow.com Judiciary Law 247 90 (10). 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. 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