Free AO 10A - Request for Examination of Report Filed by a Judicial Officer or Judicial Employee - Federal

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
NAMES OF REPORTS WHOSE DISCLOSURE REPORTS ARE REQUESTED

POSITION

Yes No

ORGANIZATIONS OR PERSONS ON WHOSE BEHALF THIS REQUEST IS MADE

ORGANIZATION(S) OR PERSON(S)

ADDRESS

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
PERSON

ADDRESS

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)

Print

Save As...

Export as FDF

Retrieve FDF File

Reset