BOARD OF BAR OVERSEERS
ANNUAL ATTORNEY REGISTRATION STATEMENT
(FOR REINSTATEMENT FROM ADMINISTRATIVE SUSPENSION
FOR NON-REGISTRATION)
PLEASE MAIL THIS FORM TO: Registration Department, Board of Bar Overseers, 99 High Street,
Boston, MA 02110
BILLING PERIOD: ___________________________________
(Billing Period To Be Completed by Registration Department)
NAME: ___________________________________________________________
(First Name, Middle Name or Initial, Last Name)
BBO NUMBER: __________________________
DATE OF ADMISSION: ____________________
STATUS: ADMINISTRATIVE SUSPENSION FOR NON-REGISTRATION
FEE DUE: Upon receipt of the completed and signed Annual Attorney Registration Statement
and Affidavit in Support of Request for Reinstatement, the Registration Department
will send you an itemization of fees by email.
Please choose Registration Status:
____
Active ____ Judicial Court:__________________
____
Inactive Position: _______________
____
Retired ____ Clerk Court: _________________
Position: _______________
OFFICE / MAILING ADDRESS: HOME ADDRESS:
_______________________________________ _______________________________________
_______________________________________ _______________________________________
_______________________________________ _______________________________________
WORK PHONE NUMBER
: ________________ HOME PHONE NUMBER: ________________
CELL PHONE NUMBER: _______________
EMAIL ADDRESS: _____________________________________________________________________
I have completed all above information including the IOLTA information and the certification of
professional liability insurance on the second page of this form and certify all information is true and
complete.
__________________________________________
SIGNATURE OF ATTORNEY
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ADDITIONAL INFORMATION FOR THE BOARD OF BAR OVERSEERS
Date of birth: ____/____/____
Names of all other jurisdictions in which you are admitted to practice and admission dates:
State Date Federal Date Administrative Bodies Date
_________________________ __________________________ ___________________________
_________________________ __________________________ ___________________________
_________________________ __________________________ ___________________________
Are you in good standing in all jurisdictions where you have been admitted to practice? Yes No
If not, please state the jurisdiction and attach statement of the circumstances. ___________________________
_________________________________________________________________________________________
CERTIFICATION OF PROFESSIONAL LIABILITY INSURANCE
I certify that I am (CHOOSE ONE):
_____ covered by professional liability insurance.
_____ not covered by professional liability insurance.
_____ not covered by professional liability insurance because I (1) practice law as a government lawyer or
am employed by an organizational client, AND (2) do not represent clients outside that capacity. You can
choose this option if you are a government attorney, military attorney or an in-house counsel of a
corporation.
COMPLIANCE STATEMENT
INTEREST ON LAWYER’S TRUST ACCOUNTS (IOLTA)
Supply your IOLTA account information or complete the REQUEST for EXEMPTION below.
_____ I have established an IOLTA account or
_____ My firm has established an IOLTA account
IOLTA ACCOUNT NAME _____________________________________________________________
LAW FIRM NAME ___________________________________________________________________
IOLTA ACCOUNT NUMBER ___________________________________________________________
BANK _____________________________________________________________________________
REQUEST FOR EXEMPTION
I am exempt from the provisions of the Massachusetts Rules of Professional Conduct Rule 1:15 because:
_____ I am not engaged in the practice of law in Massachusetts.
_____ I am engaged in the practice of law but not within a private practice and DO NOT RECEIVE
CLIENT FUNDS. (e.g. publicly employed, corporate counsel, teacher)
_____ Other - Specify: ______________________________________________________________
Any attorney who fails to fill out this IOLTA Compliance Statement is subject to suspension.
For additional information, please call the IOLTA Committee at (617) 723-9093.
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