Form Ao 10a - Request For Examination Of Report Filed By A Judicial Officer Or Judicial Employee

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Instructions
AO 10A (Rev 10/98)
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 there be
made available to me for examination the report(s) of the following named Judicial Officers or Judicial Employees:
Copy Requested
NAME
POSITION
Yes No
NAMES
OF
REPORTS
WHOSE
DISCLOSURE
REPORTS
ARE
REQUESTED
ORGANIZATIONS
ORGANIZATION(S) OR PERSON(S)
ADDRESS
OR PERSONS
ON WHOSE
BEHALF THIS
REQUEST
IS MADE
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))
PROHIBITIONS
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 falsifies, conceals, or covers up by any trick,
scheme, or device a material fact; makes any materially false, fictitious, or fraudulent statement or
representation; or 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.
NAME
ADDRESS
PERSON
OCCUPATION
MAKING
I certify under penalty of perjury that the foregoing is true and correct. (28 U.S.C. § 1746)
REQUEST
_______________________________________________
___________________________________
SIGNATURE
EXECUTED ON (DATE)
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