APPENDIX BAffidavit of Compliance for Disbarred or Suspended Attorneys INSTRUCTIONS(1)The affidavit required by section 1240.15 (f) of these Rules shall be worded and numberedas set forth below.(2)The affidavit shall be subscribed and sworn to before a notary public or other personauthorized to administer an oath.(3)The affidavit shall bear the caption and the docket number, if any, of the proceedingresulting in the respondent's disbarment or suspension.(4)In completing the affidavit, the respondent should not omit any passages. To the extent thatthe respondent is unable to swear to any of the required statements set forth in the form affidavit,the respondent must, for each such statement, alternatively explain all facts and circumstancesrelevant to why the respondent is unable to swear to the statement.(5)The affidavit shall be filed with the Court along with an affidavit reflecting service thereofupon 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 DepartmentAFFIDAVIT OF COMPLIANCE FOR DISBARRED OR SUSPENDED ATTORNEYSState of ) )ss.: County of ), being duly sworn, deposes and says that: I submit this affidavit pursuant to section 1240.15 (f) of the Uniform Rules for AttorneyDisciplinary Matters.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].The telephone numbers at which I can be contacted are:Home Work Mobile .The email address at which I can be contacted is . American LegalNet, Inc. www.FormsWorkFlow.com 7.All communications may be addressed to me at the office of my attorney,[name], at[address], 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:. 8.I was admitted to the New York State Bar on by the Department, and my attorney registration number is . 9.By order of this Court entered , I was [suspended for years -or- months -or-disbarred] from the practice of law. My use of the term "discipline" hereinafter refers to thesanction imposed by this Court in the foregoing order. A copy of the order imposing disciplineis attached as exhibit hereto. Since the entry of the order of discipline, I have complied with the order of discipline inall respects. I have also complied with Judiciary Law 247247 478, 479, 484 and 486.I have sent written notice of my to each client and anyotherparty, as required by section 1240.15 (b) of the Uniform Rules for Attorney DisciplinaryMatters.I have delivered to all clients or third parties, or to a successor attorney designated bysuch clients or third parties, all money and property in my possession (including legal files), asrequired by section 1240.15 (c) of the Uniform Rules for Attorney Disciplinary Matters.I have discontinued all attorney advertising, as required by section 1240.15 (d) of theUniform Rules for Attorney Disciplinary Matters.I have forfeited any secure pass issued to me by the Office of Court Administration, asrequired by section 1240.15 (e) of the Uniform Rules for Attorney Disciplinary Matters.I have not and will not share in any fee for legal services rendered by another attorneyduring the period of my, as precluded by section 1240.15 (g) ofthe Uniform Rules for Attorney Disciplinary Matters. For all cases in which I may have a claimfor compensation earned for work performed prior to my a motion in the appropriate forum for an order fixing my fees American LegalNet, Inc. www.FormsWorkFlow.com 16.I have made and will keep records of my compliance with this rule and the attached orderof discipline, and will make such records available in any subsequent proceeding instituted by oragainst me.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