UCS - 876 - REPORT OF COMPENSATION RECEIVED BY LAW FIRMS FOR APPOINTMENTS PURSUANT TO PART 36 OF THE RULES OF THE CHIEF JUDGE (244 36.4(d)) (Complete if total compensation from appointment of law firm325s members, associates and employees pursuant to Part 36 of the Rules of the Chief Judge exceeds $50,000 in a single calendar year (January 1 to December 31). File by March 31st following the calendar year reported.) 1.Calendar Year Reported: 2.Law Firm Tax ID Number Year ! ! ! ! TID# ! ! -!!!!!!! 3.Name of Law Firm:4.Address/Phone/FAX/ E-mail:Street City/Town/Village State Zip Phone Fax E-Mail 5.List the names and Fiduciary Identification Numbers of the members, associates and employees of the law firm for whomcompensation from appointments has been approved during the calendar year reported, and enter for each the totalcompensation approved during that year. For a member, associate or employee with no Fiduciary Identification Number(FID#), enter 322Non-List323 and his/her Social Security Number in space provided for FID# (ttach additional sheets as needed) NAME FIDUCIARY IDENTIFICATION NUMBER TOTAL APPROVED COMPENSATION IN CALENDAR YEAR REPORTED $ $ $ $ $ $ $ 6.Total of all compensation entered in item 5:Date: Signature: Print Name: Title: (e.g., managing attorney, member) American LegalNet, Inc. www.FormsWorkFlow.com