Free ATTORNEY REGISTRATION CHANGE OF INFORMATION - Connecticut

ATTORNEY REGISTRATION

CHANGE OF INFORMATION
JD-GC-10 Rev. 11-05 Pr. Bk. 2-27

STATE OF CONNECTICUT JUDICIAL BRANCH www.jud.ct.gov

FOR QUESTIONS, EMAIL [email protected] Or call (860) 568-5157

INSTRUCTIONS (1) Use this form to report any changes to information previously submitted pursuant to Practice Book Section 2-27. (2) To report ANY changes, items 1 through 3 must be completed in their entirety on the left side using the same information that was last reported. (3) For address changes or corrections, complete item 1 in its entirety in the area on the right. For Section 2, enter any corrections on the right. If extra space is needed, use back/page 2. (4) For Section 5b, enter the account information last reported on the left. Enter new account information or changes on the right and back/page 2, if applicable )

Enter All Previously Registered Information Here
1. NAME OF ATTORNEY

Enter New or Corrected Information Here
1. NAME OF ATTORNEY (Include proof of name change)

FIRM OR BUSINESS NAME (Primary law or business office)

FIRM OR BUSINESS NAME (Primary law or business office)

OFFICE ADDRESS (Number and street) CITY

P.O. BOX STATE ZIP CODE

OFFICE ADDRESS (Number and street) CITY

P.O. BOX STATE ZIP CODE

JUDICIAL DISTRICT(S) OF LAW OFFICE(S) (For Atty' with Connecticut addresses only) DATE OF BIRTH (Mo., day, yr ) JURIS NO.

JUDICIAL DISTRICT(S) OF LAW OFFICE(S) (For Atty with CT addresses only) DATE OF BIRTH (Mo., day, year) HOME ADDRESS (No., street, city, state, zip code)

HOME ADDRESS (No , street, city, state, zip code), IF DIFFERENT FROM ABOVE

2. The following is a list of all OTHER jurisdictions (States and District of Columbia only) where I have ever been admitted to practice as a lawyer:
YEAR STATE YEAR STATE YEAR STATE

2. The following is a list of all OTHER jurisdictions (States and District of Columbia only) where I have ever been admitted to practice as a lawyer:
YEAR STATE YEAR STATE YEAR STATE

NONE 3. I engage in the private practice of law in the State of Connecticut. YES PRO HAC VICE NOT AT ALL (Stop here and sign at bottom) RETIRED (Stop here and sign at bottom)

NONE 3. I engage in the private practice of law in the State of Connecticut. YES PRO HAC VICE NOT AT ALL (Stop here, sign at bottom) RETIRED (Stop here, sign at bottom)

4. I, individually or through the firm with which I am associated, participate in IOLTA (Interest on Lawyer's Trust Accounts) pursuant to Rule 1.15 of the Rules of Professional Conduct: YES NO

4. I, individually or through the firm with which I am associated, participate in IOLTA (Interest on Lawyer's Trust Accounts) pursuant to Rule 1.15 of the Rules of Professional Conduct: YES NO

5a. I do NOT maintain a fiduciary account.

("X" here )

5a. I do NOT maintain a fiduciary account.

("X" here )

5b. I, individually or through the firm with which I am associated, maintain the following fiduciary account(s) in which the funds of more than one client are kept in the financial institution(s) specified on the continuation page. (See P.B. § 2-28(c)) (To be completed only if answer to 3 is "yes" or "pro hac vice". (If no account is maintained leave blank; Associate and Of Counsel list firm information.)

5b. I, individually or through the firm with which I am associated, maintain the following fiduciary account(s) in which the funds of more than one client are kept in the financial institution(s) specified on the continuation page. (See P.B. § 2-28(c)) (To be completed only if answer to 3 is "yes" or "pro hac vice". (If no account is maintained leave blank; Associate and Of Counsel list firm information.)

CERTIFICATION
I certify that the information provided is true. If any statements are willfully false, I realize I am subject to discipline by the Superior Court.
ATTORNEY'S SIGNATURE DATE

X

Retain a copy for your records and mail original to: STATEWIDE GRIEVANCE COMMITTEE, ATTORNEY REGISTRATION, 2nd Floor, Suite Two, 287 Main Street, East Hartford, CT 06118-1885

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NAME OF ATTORNEY (From page 1)

JURIS NO. (From page 1)

Enter All Previously Registered Information Here
ACCT. NO.: FINANCIAL INSTIT.: CITY: ACCT. NO.: FINANCIAL INSTIT.: CITY:

Enter New or Corrected Information Here

ACCT. NO.: FINANCIAL INSTIT.: CITY:

ACCT. NO.: FINANCIAL INSTIT.: CITY:

ACCT. NO.: FINANCIAL INSTIT.: CITY:

ACCT. NO.: FINANCIAL INSTIT.: CITY:

ACCT. NO.: FINANCIAL INSTIT.: CITY:

ACCT. NO.: FINANCIAL INSTIT.: CITY:

JD-GC-10 Attorney Registration Change of Information Continuation Page, Rev. 11-05

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