Fill and Sign the Blank Court Forms

REPLACEMENT ATTORNEY LICENSING STATEMENT For Use By Those Who Are Seeking Reinstatement ONLY Firm/ Business/Official Address ** Street or P.O. Box City, State, ZIP Email Address (Required)** Telephone Number FAX Number (optional) Vermont IOLTA Account Information (REQUIRED) FAQs on IOLTA accounts are available here Further questions regarding IOLTA requirements should be directed to vbarfoun@accessvt.com Vermont IOLTA Bank Account Number or "Exempt" Bank Name or Reason for "Exemption" Street or P.O. Box City, State, ZIP Full Name Formerly Known As Attorney License Number List all other State jurisdictions to which you have been admitted to the practice of law: Name of Jurisdiction: Year of Admission: Status Name of Jurisdiction: Year of Admission: Status I am filing as ACTIVE and have enclosed a check for $__________ I am filing as INACTIVE and have enclosed a check for $____________. I will not be practicing law in Vermont. By my signature, I certify that I am in good standing with respect to any and all taxes due the State of Vermont. I also certify that I am not under an obligation to pay child support, or that I am in good standing with respect to any and all child support payable. ____________________________________________________ SignatureINSTRUCTIONS: This is a fillable form; to begin, click on a section, then tab to all other sections. Should you experience difficulty, you may print out this form and fill it in by hand. Fill out the form, print and sign, keeping a copy for yourself. Mail this fully completed form with the appropriate fee to ATTORNEY LICENSING, 2418 Airport Road, Suite 2, Barre, VT 05641 along with the Replacement CLE Affidavit, if required. Checks should be made payable to Attorney Licensing. Questions should be directed to jud-attylicensing@state.vt.us Date Date of Birth (optional) If none, check here: **PLEASE NOTE: The office address and email address you provide on this statement will be considered your official address for any notification by the trial courts and the licensing office. It is your responsibility to notify us of changes to your mailing or email address by contacting us at jud-attylicensing@state.vt.us. If a court delivers some or all notices by electronic mail, and the attorney fails to maintain a reported, operable electronic mail address, notice is sufficient if available on inquiry at the courthouse. See A.O. 41, Section 7. Residence Address Please attach a separate page for additional IOLTA accounts (If Known)