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STATE OF NEW YORK

GRIEVANCE COMMITTEE

FOR THE NINTH JUDICIAL DISTRICT

Crosswest Office Center

399 Knollwood Road, Suite 200

White Plains, New York 10603

PLEASE USE INK

Date: ___________

A. COMPLAINANT:

(your full name): __________________________________________________________

(signature): _______________________________________________________________

(address): ________________________________________________________________

(City): ________________________________ (State): ____________ (Zip): __________

(phone): _________________________________________________________________

B. ATTORNEY COMPLAINED OF:

(your full name): __________________________________________________________

(address): ________________________________________________________________

(City): ________________________________ (State): ____________ (Zip): __________

(phone): _________________________________________________________________

C. COMPLAINTS TO OTHER AGENCIES:

Have you filed a complaint concerning this attorney with another Bar Association,

District Attorney's Office or any other Agency? O Yes O No

If so, name the Agency and action taken: ______________________________________

_________________________________________________ __________________________