Fill and Sign the Edgar Filer Manual Volume Ii Edgar Filing Version 11 Form

ATTORNEY LICENSING STATEMENT Group II (July 1, 2007 - June 30, 2009) Firm/ Business/Official Address ** Street or P.O. Box City, State, ZIP Email Address (REQUIRED) ** Telephone Number FAX Number (optional) REQUIRED Vermont IOLTA Account Information FAQs on IOLTA accounts are available at http://www.brandsystems.net/vtbar/attorneyresources/ reports/ioltafaq.pdf Further questions regarding IOLTA requirements should be directed to dbailey@vtbarfndn.org Vermont IOLTA Bank Account Number or "Exempt" Bank Name or Reason for "Exemption" Street or P.O. Box City, State, ZIP Full NameFormerly 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 $400.00 I am filing as INACTIVE and have enclosed a check for $150.00. I will not be practicing law in Vermont. I am retiring/resigning from the practice of law as of I understand that reinstatement 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 goodstanding with respect to any and all child support payable. ____________________________________________________ Signature INSTRUCTIONS: 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 and CLE affidavit, if previously licensed as active, to ATTORNEY LICENSING, 2418 Airport Road, Suite 2, Barre, VT 05641 as soon as possible to avoid suspension of your license topractice law . Checks should be made payable to ATTORNEY LICENSING. Automatic suspension from the practice of law will occur after July 2. A $100 reinstatement fee will be charged in addition to the licensing fee after suspension. Be sure to allow sufficient time for mail delivery. Incomplete forms will be returned and no additional time for completion will be given.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 electronicmail, and the attorney fails to maintain a reported, operable electronic mail address, notice is sufficient if available on inquiryat the courthouse. See A.O. 41, Section 7. requires readmission. Residence Address Please attach a separate page for additional IOLTA accounts Attorney Information Select One Select One