CIRCUIT RULE 26.1 DISCLOSURE STATEMENT

Appellate Court No: _________________

Short Caption:_________________________________________________

To enable the judges to determine whether recusal is necessary or appropriate, an attorney for a non-governmental party or amicus curiae, or a private attorney representing a government party, must furnish a disclosure statement stating the following information in compliance with Circuit Rule 26.1 and Fed. R. App. P. 26.1 .

The Court prefers that the disclosure statement be filed immediately following docketing; but, the disclosure statement must be filed within 21 days of docketing or upon the filing of a motion, response, petition, or answer in this court, whichever occurs first. Attorneys are required to file an amended statement to reflect any material changes in the required information. The text of the statement must also be included in front of the table of contents of the party's main brief. Counsel is required to complete the entire statement and to use N/A for any information that is not applicable if this form is used.

(1) The full name of every party that the attorney represents in the case (if the party is a corporation, you must provide the corporate disclosure information required by Fed. R. App. P. 26.1 by completing the item #3):
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________

(2) The names of all law firms whose partners or associates have appeared for the party in the case (including proceedings in the district court or before an administrative agency) or are expected to appear for the party in this court:
______________________________________________________________________
______________________________________________________________________

(3) If the party or amicus is a corporation:

i) Identify all its parent corporations, if any; and
______________________________________________________________________

ii) list any publicly held company that owns 10% or more of the party's or amicus' stock:
______________________________________________________________________
______________________________________________________________________



Attorney's Signature:____________________________________Date:________________________

Attorney's Printed Name:_____________________________________________________________

Please indicate if you are Counsel of Record for the above listed parties pursuant to Circuit Rule 3(d). Yes___ No ___.

Address:__________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

Phone Number:__________________________________Fax Number:__________________________

E-Mail Address:_____________________________________________________________________

rev. 11/01 AK