Appendix B JUDICIAL COUNCIL OF THE ELEVENTH CIRCUIT COMPLAINT OF JUDICIAL MISCONDUCT OR DISABILITY UNDER CHAPTER 16 To file a complaint of judicial misconduct or disability, please answer all of the questions on this form and send three copies in an envelope to the Clerk, United States Court of Appeals, 56 Forsyth Street, N.W. , Atlanta, Georgia 30303. Please write “ Chapter 16 Complaint” on the envelope. Do not write the name of the complained-of judge on the envelope. This complaint must be legible; if possible, it should be typewritten. For other details, see the Rules of the Judicial Council of the Eleventh Circuit Governing Complaints of Judicial Misconduct or Disability. CONFIDENTIAL IN THE MATTER OF A COMPLAINT FILED BY: ________________________________________________________________________ NAME OF COMPLAINANT ______________________________________________________________________________________ ADDRESS ______________________________________________________________________________________ ( ___________ ) _____________________________ DAYTIME TELEPHONE NUMBER AGAINST: ______________________________________________________________________________________ NAME OF COM PLAINED-OF JUDGE ______________________________________________________________________________________ COURT 1 Rev.: 12/03 American LegalNet, Inc. www.FormsWorkflow.com 1. G Yes Does this complaint concern a particular law suit? G No If yes, please pr ovide the fo llowing inform ation abo ut the lawsuit. (If more than one lawsuit is invo lved, use ad ditional pag es, as necessa ry.) _________________________________________________________________________________________ COURT IN WHICH LAWSUIT WAS FILED ______________________________________ ___________________________________________ DOCKET NUMBER DOCKET NUMBER OF APPEAL, IF ANY What is (o r was) your ro le in the lawsuit? G Party (including pro se) G Attorney G Juror G Witness G None of these Please pr ovide the na me, addr ess, and telep hone num ber of your a ttorney in this lawsuit: 2. G Yes Have you filed a lawsuit against the judge? G No If yes, please pr ovide the fo llowing inform ation abo ut the lawsuit. (If more than one lawsuit is invo lved, use ad ditional pag es, as necessa ry.) _________________________________________________________________________________________ COURT IN WHICH LAWSUIT WAS FILED ______________________________________ ___________________________________________ DOCKET NUMBER DOCKET NUMBER OF APPEAL, IF ANY _________________________________________________________________________________________ PRESENT S TATUS OF LAWSUIT OR APP EAL Please pr ovide the na me, addr ess, and telep hone num ber of your a ttorney: 3. On separate sheets of paper, no larger than the paper on which this form is printed, please describe the evidence of misconduct or disability that is the subject of this complaint. Do not use more than five single-sided page s. 4. Sign your name. I declare un der pena lty of perjury that I have read Rule 1 of the Rules of the Judicia l Council of the Eleventh Circuit Governing Co mplaints of Ju dicial Misc onduct an d Disability, an d that the statem ents made in this complaint are true and correct to the best of my knowledge. _______________________________________________ ___________________________________ SIGNATURE OF COMPLAINANT DATE Rev.: 12/03 2 American LegalNet, Inc. www.FormsWorkflow.com