Fill and Sign the Asd Amp Counsel for Discipline Use Only Date Request Recd Form

ATTORNEY ’S FORM TO REQUEST A TRANS FER OF M EMBERSHIP STATUS TO DISABILITY INACTIVE STATUS For attorneys seeking to transfer their membership status from active or inactive to the disability in active status. Complete this form to inform The Supreme Court of an attorney’s request for disability inactive status pursuant to §3-311 (C). Include additional documentation/documents with this form as required below . PART A: ATTORNEY CONTACT INFORMATION The address provided here will be considered the current and preferred address for the attorney . You must provide a current email address. Name: Bar #: Firm/Org.: Address: City State ZIP Email: Phone: PART B: EXPLANATION OF STATUS AND TRANSFER INFORMATION This section provides an explanation of the disability inactive status and the type of transfer requested . EXPLANATION OF DISABILITY INACTIVE STATUS PURSUANT TO NEB . CT. R. §3 -311 Full text of the rule can be accessed at: https://supremecourt.nebraska.gov/ . • Disability inactive status is intended for attorneys unfit for practice due to incapacitation for physical or mental illness or addiction . • Upon the Court’s determination of incapacitation, any pending disciplinary matters against the attorney will be held in abeyance. • Attorneys on disability inactive status shall not be required to pay mandatory membership assessments as required by Neb. Ct. R. § 3- 803(D). • Any attorney on disability inactive status under the provisions of the rule shall be entitled to apply for reinstatement by filing with the Court an application supported by evidence that the attorney’s disability has been removed and the attorney is capable of resuming t he practice of law. TRANSFER INFORMATION Indicate the type of transfer requested. Active to Disability Inactive Transfer Includes attorneys currently in the Regular, Senior, Junior, Judicial and Military Active statuses request ing Disability Inactive status. Inactive to Disability Inact ive Transfer Includes attorneys currently in the Regular and Emeritus Inactive status es request ing Disability Inactive status. PART C: REQUIRED INFORMATION AND VERIFICATION This section provides an explanation of the disability inactive status and the type of transfer requested . REQUIRED INFORMATION Attach a statement providing documentation of the underlying condition that supports a transfer to Disability Inactive status including a statement from a treating physician regarding the nature of the condition and opinion regarding ability to practice law. VERIFICATION By checking this box and submiss ion of this form, I request that my attorney license be placed into the Disability Inactive Status. Upon request of the Court, Counsel for Discipline or Attorney Services Division, I agree to provide further documentation or records if necessary to verify or explain my condition or incapacitation. I understand the outcome of my request will be determined by the Nebraska Supreme Court with cooperation or recommendation by Counsel for Discipline . Signature: Date: Digital signatures are not accepted. Submit this form to NSC Attorney Services Division for submission to the Supreme Court , 3806 Normal Blvd, Lincoln, NE 68506 HELP DESK: 402.471.3137; fax: 402.471. 2512; email: nsc.attrservices@nebraska.gov - ASD & COUNSEL FOR DISCIPLINE USE ONLY - DATE REQUEST REC’D: ________________________ • ASD REVIEW BY & DATE: ____________________ • CforD REVIEW BY & DATE: ___________________ NOTES /RESULT : _____________________________ __________________________________________ __________________________________________ __________________________________________ ASD 3:13 New 01/19