JUDICIAL COUNCIL OF THE SIXTH CIRCUIT
COMPLAINT OF JUDICIAL CONDUCT OR DISABILITY

 MARK ENVELOPE "JUDICIAL MISCONDUCT COMPLAINT" OR "JUDICIAL DISABILITY COMPLAINT."
DO NOT PUT THE NAME OF THE JUDGE OR MAGISTRATE ON THE ENVELOPE.

SEE RULE 2 FOR THE NUMBER OF COPIES REQUIRED.

1. Complainant's Name: _____________________________________________________
   Address: ______________________________________________________________
   ______________________________________________________________________
   
   Daytime telephone: (     ) ____________________

2. Judge or Magistrate complained about:
   
   Name: ________________________________________________________________
   
   Court: ________________________________________________________________

3. Does this complaint concern the behavior of the judge or magistrate in a
   particular lawsuit or lawsuits?
                             Yes_____                No_____

If "yes" give the following information about each lawsuit
(use reverse side if there is more than one):

Court: ________________________________________________________________

Docket number: ________________________________________________________

Are (were) you a party or lawyer in the lawsuit?

______Party     _____Lawyer    _____Neither

If a party, give the following information:

Lawyer's Name: ________________________________________________________

Address: ______________________________________________________________

______________________________________________________________________

Telephone: (     ) _________________________
Docket number(s) of any appeals of above case(s) to the Sixth Circuit Court of

Appeals: ______________________________________

4. Have you filed any lawsuits against the judge or magistrate?
                           ______Yes    ______No
   
   If yes give the following information about each lawsuit
   (use the reverse side if there is more than one):
   
   Court: ____________________________________________________
   
   Docket Number: ___________________________________________
   
   Present status of suit: ________________________________________
   
   Your Lawyers Name: ___________________________________________
   
   Address: _____________________________________________________
   
   ______________________________________________________
   
   Telephone: (     ) ___________________________________
   
   Court to which any appeal has been taken: ________________________________________________
   
   Docket number of the appeal: ______________________________________________
   
   Present status of the appeal: _______________________________________________

5. On separate sheets of paper, not larger than the paper this form is printed
   on, describe the conduct or the evidence of disability that is the subject of
   this complaint. See rule 2 (b) and rule 2 (d). Do not use more than 5 pages (5
   sides). Most complaints do not require that much.

6. You should either
   
   (1) check the first line below and sign this form in the presence of a notary
   public; or
   
   (2) check the second line and sign the form. You do not need a notary public if
   you check the second line.
   
   ______ I swear (affirm) that --
   
   ______ I declare under penalty of perjury that  
   
   (1) I have read rules 1 and 2 of the Rules of the Sixth Circuit Governing
   Complaints of Judicial Misconduct or Disability, and
   
   (2) The statements made in this complaint are true and correct to the best of
   my knowledge.