JUDICIAL COUNCIL OF THE FOURTH CIRCUIT COMPLAINT OF JUDICIAL MISCONDUCT OR DISABILITY To begin the complaint process, complete this form and prepare the brief statement of facts described in item 5 (below). The RULES FOR JUDICIAL-CONDUCT AND JUDICIAL-DISABILITY PROCEEDINGS, adopted by the Judicial Conference of the United States, contain information on what to include in a complaint (Rule 6), where to file a complaint (Rule 7), and other important matters. The rules are available in federal court clerks’ offices; on individual federal courts’ Web sites, including www.ca4.uscourts.gov; and on www.uscourts.gov. Your complaint (this form and the statement of facts) should be typewritten and must be legible. Only the original is required to be filed. Enclose each copy of the complaint in an envelope marked “COMPLAINT OF MISCONDUCT” or “COMPLAINT OF DISABILITY” and mail it to Clerk, United States Court of Appeals, 1100 East Main Street, Suite 501, Richmond, Virginia, 23219-3517. Do not put the name of any judge on the envelope. 1. Name of Complainant: ___________________________________ Contact Address: ________________________________________ ________________________________________ Daytime telephone: ( ____ ) ________________________ 2. Name(s) of Judge(s): _____________________________________ Court: _________________________________________________ 3. Does this complaint concern the behavior of the judge(s) in a particular lawsuit or lawsuits? [ ] Yes [ ] No If "yes," give the following information about each lawsuit: Court: __________________________________________________ Case number: ____________________________________________ Docket numbers of any appeals to the Fourth Circuit: _____________________________ Are (were) you a party or lawyer in the lawsuit? [ ] Party [ ] Lawyer [ ] Neither If you are (were) a party and have (had) a lawyer, give the lawyer’s name, address, and telephone number: _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ Page 1 of 2 American LegalNet, Inc. www.FormsWorkflow.com 4. Have you filed any lawsuits against the judge? [ ] Yes [ ] No If "yes," give the following information about each lawsuit: Court: ___________________________________________________ Case number: _____________________________________________ Present status of lawsuit: ____________________________________ Name, address, and telephone number of your lawyer for the lawsuit against the judge: ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ Court to which any appeal has been taken in the lawsuit against the judge: ________________________________________________________________ Docket number of the appeal: ________________________________________ Present status of the appeal: __________________________________________ 5. Brief Statement of Facts. Attach a brief statement of the specific facts on which the claim of judicial misconduct or disability is based. Include what happened, when and where it happened, and any information that would help an investigator check the facts. If the complaint alleges judicial disability, also include any additional facts that form the basis of that allegation. 6. Declaration and signature: I declare under penalty of perjury that the statements made in this complaint are true and correct to the best of my knowledge. (Signature)________________________________ (Date)_________________________ Page 2 of 2 American LegalNet, Inc. www.FormsWorkflow.com