AO 10A (Rev. 03/17)REQUEST FOR EXAMINATION OF REPORT FILED BYA 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 thefollowing named Judicial Officers or Judicial Employees be sent to me in electronic form. By checking this box, I am requestinga paper copy rather than an electronic copy (See instructions).NAMEPOSITIONYEAR(S) REQUESTEDNAMESOFINDIVIDUALSWHOSEDISCLOSUREREPORTSAREREQUESTEDORGANIZATIONSOR PERSONSON WHOSEBEHALF THISREQUESTIS MADENAMEADDRESSPROHIBITIONSI understand that the statute makes it unlawful to obtain or use this or these reports for: any unlawful purpose; any commercialpurpose other than by news and communication media for dissemination to the general public; determining or establishing ofthe credit rating of any individual; or use, directly or indirectly, in the solicitation of money for any political, charitable, orother purpose (5 U.S.C. App. 4 247 105(c)).I understand that whoever, in any manner within the jurisdiction of the executive, legislative, or judicial branch of theGovernment of the United States, knowingly and willfully (1) falsifies, conceals, or covers up by any trick, scheme, or device amaterial fact; (2) makes any materially false fictitious, or fraudulent statement or representation; or (3) makes or uses any falsewriting or document, knowing the same to contain any materially false, fictitious, or fraudulent statement or entry, shall befined not more than $10,000 or imprisoned not more than five years, or both (18 U.S.C. 247 1001).I am aware of the prohibitions on the obtaining and use of this information, as are stated above, and that this request forexamination is a matter of public record.PERSONMAKINGREQUESTName:Occupation:Phone Number:Email Address:Mailing Address:I certify under penalty of perjury that the foregoing is true and correct. (28 U.S.C. 247 1746)SignatureDate executed American LegalNet, Inc. www.FormsWorkFlow.com Instructions for Requesting a Copy of a Financial Disclosure Reportfrom the Financial Disclosure OfficeThese instructions provide you with the information necessary to request a copy of a judge's or a judiciary employee'sfinancial disclosure report filed with the Administrative Office of the U.S. Courts in accordance with the requirements ofthe Ethics in Government Act of 1978, as amended (Act) (5 U.S.C. app. 247247 101-111). Before a financial disclosure reportcan be released, a Form AO 10A, Request for Examination of Report Filed by Judicial Officer or Judicial Employee, mustbe 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 DisclosureOffice. Questions concerning the completion of the Form AO 10A, or the report request process, should be directed to theFinancial 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 theForm AO 10A. Section 105(b)(2)(B) requires that if you are obtaining a report at the request of, or on behalf of, anotherindividual or an organization, you must specifically list that individual or organization in the appropriate block on theform. Section 105(b)(3)(C) requires you to sign the request form indicating that you are aware of the prohibitions onwrongful use as delineated on the form and in section 105(c)(1) of the Act. Failure to comply with these statutoryrequirements is cause to deny your request. It is helpful to provide a phone number and email address where you can bereached 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 apaper copy of a report, you must check the appropriate box on the Form AO 10A. The reproduction cost for a paper copyof a financial disclosure report is $0.20 per page. The Financial Disclosure Office only accepts checks and money ordersfor the exact amount provided to you. Your check or money order should be made payable to the Administrative Officeof the United States Courts. Paper copies of a report will not be mailed until payment has been received. American LegalNet, Inc. www.FormsWorkFlow.com