UNITED STATES COURT OF APPEALS FOR THE SIXTH CIRCUIT QUESTIONNAIRE l. Name 2. Address 3. Telephone Fax 4. Social Security Number 5. Initial Below your choice of how payments should be reported to the IRS. ________ Under my social security number and name, as indicated above. ________ To the law firm to which I am affiliated. The law firm’s Taxpayer Identification Number, Name and Address are: Taxpayer Identification Number of Law Firm Name of Law Firm Address (Signature) (Date) American LegalNet, Inc. www.USCourtForms.com Page 1 6. Nearest U.S. District Court location 7. Bar Admissions: 8. State bar registration number(s) (if applicable): 9. Law school attended 10. Law school honors: 11. Type of practice: Date of Degree How long? American LegalNet, Inc. www.USCourtForms.com Page 2 l2. Professional publications: FEDERAL LITIGATION EXPERIENCE l3. Have you participated as counsel of record in any proceedings in a United States District Court? If "yes,” please indicate which court, and the name and docket numbers of the proceedings. l4. Have you participated as counsel of record in any proceedings before the United States Court of Appeals for the Sixth Circuit, or any of the other federal circuits? If "yes,” please indicate which court, and the name and docket numbers of the proceedings. l5. Have you appeared before the United States Supreme Court? If "yes,” please indicate the names and docket numbers of the proceedings. l6. Have you previously received appointments to represent itigants before this court? If "yes,” please indicate case name and docket numbers. American LegalNet, Inc. www.USCourtForms.com Page 3 l7. Are you currently a member of a panel maintained by a district court or Federal Public Defender office for appointment in district court proceedings? If "yes,” please specify. _____ I am interested in accepting Criminal Justice Act appointments from the Court of Appeals, under the guidelines set forth in the Act and the Sixth Circuit Plan for implementation of the Act. I will accept appointment in 28 U.S.C. §2254 cases from the following state(s): _____Michigan _____Ohio _____Kentucky _____Tennessee I will accept appointment in appeals in criminal proceedings, and in appeals from actions brought under 28 U.S.C. §2255. _____Yes _____No I will accept appointment in non-Criminal Justice Act cases, understanding that there is no statutory authority for the court to compensate me for my time, although it will reimburse me my necessary and reasonable expenses incurred in such representation. _____Yes _____No (Signature) (Date) American LegalNet, Inc. www.USCourtForms.com Page 4