[address], and I hereby authorize my attorney to accept and acknowledge receipt of any and all
legal documents or other notices on my behalf.
- OR -
All communications may be addressed to me personally at the following address:
_________________________.
8.
I was admitted to the New York State Bar on [date] by the ___________ Judicial
Department, and my attorney registration number is ___________.
9.
By order of this Court entered [date], I was [suspended for ____ years -or- months -or-
disbarred] from the practice of law. My use of the term "discipline" hereinafter refers to the
sanction imposed by this Court in the foregoing order. A copy of the order imposing discipline
is attached as exhibit ___ hereto.
10.
Other than the location specified in paragraph 4 hereof, I have resided at the following
addresses since the entry of the order of discipline: [in chronological order state the approximate
dates of residence, street, town or city, state, and zip code].
- OR -
I attest that I have resided continually at the location specified in paragraph 4 hereof since the
entry of the order of discipline.
11.
The discipline imposed upon me was predicated upon, or arose out of, my
misappropriation or misuse of the real or personal property of others, or the failure to return legal
fees received but unearned by me. I have made full restitution to the owners of the property or
the clients in question, and if any part of a loss occasioned by my conduct was the subject of an
award by the Lawyers' Fund for Client Protection pursuant to Part 7200 of this Title, I have made
full restitution to the Fund, except as follows:
[A statement listing each property, its dollar value, the name of the true owner, and the extent to
which I have made or have yet to make restitution is attached as exhibit ____ hereto.]
- OR -
I attest that the discipline imposed upon me was not predicated upon, and did not arise out of,
charges that I willfully misappropriated or misapplied money or property in the practice of law.
12.
On the date the order of discipline was entered, the following matters, which were not the
basis of this Court's order, were pending against me before any attorney grievance committee in
the State of New York: [state the nature of the complaint, the disciplinary authority before which
it was pending, and the disposition thereof].
- OR -
I attest that, on the date the order of discipline was entered, no additional matters were pending
against me before any attorney grievance committee in the State of New York
13.
I have also been admitted to practice in the following courts or jurisdictions:
_________________.
[Certificates of Good Standing, issued within the 30 days preceding the execution of this
affidavit by all such courts or jurisdictions in which I am currently admitted to practice, except