AO 10A (Rev. 03/17) REQUEST FOR EXAMINATION OF REPORT FILED BY A JUDICIAL OFFICER OR JUDICIAL EMPLOYEE In accordance with section 105 of the Ethics in Government Act of 1978, as amended, I request that the report of the following named Judicial Officers or Judicial Employees be sent to me in electronic form. By checking this box, I am requesting a paper copy rather than an electronic copy ' (See instructions). NAME POSITION YEAR(S) REQUESTED NAMES OF INDIVIDUALS WHOSE DISCLOSURE REPORTS ARE REQUESTED ORGANIZATIONS OR PERSONS ON WHOSE BEHALF THIS REQUEST IS MADE NAME ADDRESS I understand that the statute makes it unlawful to obtain or use this or these reports for: any unlawful purpose; any commercial purpose other than by news and communication media for dissemination to the general public; determining or establishing of the credit rating of any individual; or use, directly or indirectly, in the solicitation of money for any political, charitable, or other purpose (5 U.S.C. App. 4 § 105(c)). I understand that whoever, in any manner within the jurisdiction of the executive, legislative, or judicial branch of the Government of the United States, knowingly and willfully (1) falsifies, conceals, or covers up by any trick, scheme, or device a material fact; (2) makes any materially false fictitious, or fraudulent statement or representation; or (3) makes or uses any false writing or document, knowing the same to contain any materially false, fictitious, or fraudulent statement or entry, shall be fined not more than $10,000 or imprisoned not more than five years, or both (18 U.S.C. § 1001). I am aware of the prohibitions on the obtaining and use of this information, as are stated above, and that this request for examination is a matter of public record. PROHIBITIONS Name: Phone Number: PERSON MAKING REQUEST Occupation: Email Address: Mailing Address: I certify under penalty of perjury that the foregoing is true and correct. (28 U.S.C. § 1746) Signature Date executed American LegalNet, Inc. www.FormsWorkFlow.com Instructions for Requesting a Copy of a Financial Disclosure Report from the Financial Disclosure Office These instructions provide you with the information necessary to request a copy of a judge's or a judiciary employee's financial disclosure report filed with the Administrative Office of the U.S. Courts in accordance with the requirements of the Ethics in Government Act of 1978, as amended (Act) (5 U.S.C. app. §§ 101-111). Before a financial disclosure report can be released, a Form AO 10A, Request for Examination of Report Filed by Judicial Officer or Judicial Employee, must be completed. Each judge or employee whose report you request must be listed by name on the form. The Form AO 10A may be obtained from the judiciary's website at www.uscourts.gov or from the Financial Disclosure Office. Questions concerning the completion of the Form AO 10A, or the report request process, should be directed to the Financial Disclosure Office at (202) 502-1850, or by fax at (202) 502-1899. Please note that section 105(b)(2)(A) of the Act requires that you provide your name, occupation, and address on the Form AO 10A. Section 105(b)(2)(B) requires that if you are obtaining a report at the request of, or on behalf of, another individual or an organization, you must specifically list that individual or organization in the appropriate block on the form. Section 105(b)(3)(C) requires you to sign the request form indicating that you are aware of the prohibitions on wrongful use as delineated on the form and in section 105(c)(1) of the Act. Failure to comply with these statutory requirements is cause to deny your request. It is helpful to provide a phone number and email address where you can be reached in case there is a question relating to your request. All financial disclosure reports will be provided on an electronic storage device at no charge. If you wish to receive a paper copy of a report, you must check the appropriate box on the Form AO 10A. The reproduction cost for a paper copy of a financial disclosure report is $0.20 per page. The Financial Disclosure Office only accepts checks and money orders for the exact amount provided to you. Your check or money order should be made payable to the Administrative Office of the United States Courts. Paper copies of a report will not be mailed until payment has been received. After completing the Form AO 10A, you must return the form to the Financial Disclosure Office, Administrative Office of the United States Courts, Suite 2-301, One Columbus Circle, N.E., Washington, D.C. 20544; email it to CommitteeonFinancialDisclosure@ao.uscourts.gov (with Form AO 10A in the subject line); or fax it to (202) 502-1899. Upon receipt of the Form AO 10A, each judge or employee will be notified that you requested his or her report, then a copy of the requested report will be sent to you. If a paper copy is requested, you will be notified of the cost. American LegalNet, Inc. www.FormsWorkFlow.com