Designation Of Personal Legal Representative - U.s. Office Of Special Counsel

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U.S. OFFICE OF SPECIAL COUNSEL
Designation of Personal Legal Representative
OSC Case No. _______________________________
By signing this form you indicate that you have voluntarily chosen the attorney designated below to
serve as your personal legal representative in the above-mentioned U.S. Office of Special Counsel (OSC)
matter. The attorney designated by you must also indicate agreement to such designation by signing below.
In limited instances where your employer has found it appropriate, you may request to have an
attorney from your agency represent you in this matter. You are not required to do so. You may proceed
with a private attorney or with no attorney. If you choose to have an attorney from your agency personally
represent you, you understand that a conflict of interest may arise by virtue of that attorney’s responsibilities
to his or her employer, the agency, which may require that attorney to withdraw from representing you.
I hereby designate ________________________ to serve as my personal legal representative during
the course of this OSC investigation.
__________________________________
____________________________
Name of Individual
Date
__________________________________
Signature of Individual
Private Attorney
__________________________________
____________________________
Name of Personal Legal Representative
Date
__________________________________
Signature of Personal Legal Representative
Telephone Number:
_____________________________________________________________________
Email Address:
_____________________________________________________________________
Address:
_____________________________________________________________________
Federal Agency Attorney
I am an attorney for the Federal Government and have provided notice to my agency, including the
Designated Agency Ethics Official, to represent the above-named individual in the above-referenced OSC
matter. For purposes of this investigation, I represent the individual in his or her personal capacity; I am not
representing the agency in this matter.
__________________________________
____________________________
Name of Personal Legal Representative
Date
__________________________________
Signature of Personal Legal Representative
Telephone Number:
_____________________________________________________________________
Email Address:
_____________________________________________________________________
Address:
_____________________________________________________________________

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