Registration number Effective date of registration
Title and description of this work:
The copy of this material should be:
Uncertified Certified (additional fee applies) Expedited (additional fee applies)
The copy of this material is to be used for the following actual or prospective litigation:
Name of client:
Address:
City: State: Zip:
Phone:
( ) Fax:
( ) Email:
Client is (or may become):
Name(s) of other party/parties:
Plaintiff Defendant
Nature of the controversy:
Name of court if proceedings have been instituted:
Docket number:
Caption:
If litigation is prospective, please give a full statement of the facts surrounding the controversy (attach additional sheets if necessary).
Attach any letter or other document that supports your claim that litigation may be instituted.
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Complete all applicable spaces (number 3) on the reverse side of this page.
Read all information and sign number 4.
DO NOT WRITE HERE
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Pursuant to 17 USC §706(b) and 37 CFR §201.2(d)(2)(ii), please make a copy of the deposit described below.
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Litigation Statement · Form LS
United States Copyright Office, Certifications and Documents Section
Request for Reproduction of Copies, Phonorecords, or Identifying Material Deposited in Connection with Copyright Registration
BASIC INSTRUCTIONS
This form
must
be used to request copies of copyright deposits pursuant to 37 CFR §201.2(d)(2)(ii). This form
must
contain a signature
and
all
information requested in order for the Office to process the request. A separate Form LS must be used for each work requested.
The person who picks up copies must present photo identification.

:
Material requested
must only
be used for specific litigation noted.
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     
   
  

FORM LS





     
  : 03/2019 Printed on recycled paper ..   : 2019-xxx-xxx
Printed name of requesting attorney or pro se litigant:
Name of firm:
Address
(no P.O. boxes):
City: State: Zip:
Phone:
( ) Fax:
( ) Email:
The requested material should be mailed to the address above
will be picked up by:
Individual’s name or name of messenger service
use requesting patrons FedEx account:
Account number
Any false statement of a material fact made on this form may be a criminal offense. See 18 U.S.C. §1001(a), reprinted below. The Copyright
Office may report misrepresentations or misconduct to Federal enforcement agencies or the appropriate bar association(s).
I hereby declare to the Copyright Office, under penalty of perjury, that a controversy exists and that the requested copy will be used only in
connection with the specified actual or prospective litigation. I also acknowledge that any other use of this copy would be in violation of the
Regulations of the Copyright Office 37 CFR §201.2(d)(2).
Signature of
Attorney: Bar number
State of practice
Date
Pro se litigant (
individual serving as his or her own attorney
)
Return this form by mail to:
Records Research and Certication Section, U.S. Copyright Oce, P.O. Box 70400,
Washington, DC 20024
or by email to:
coplitigationsupport@copyright.gov
37 CFR §201.2(d)(2)(ii)
(2) Requests for certified or uncertified reproductions of the copies, phonorecords, or identifying material deposited in connection with
a copyright registration of published or unpublished works in the custody of the Copyright Office will be granted only when one of the
following three conditions has been met:
***
(ii) The Copyright Office receives a written request from an attorney on behalf of either the plaintiff or defendant in connection with
litigation, actual or prospective, involving a copyrighted work. The following information must be included in such a request: (A) The names
of all the parties involved and the nature of the controversy; (B) The name of the court in which the actual case is pending or, in the case
of a prospective proceeding, a full statement of the facts of the controversy in which the copyrighted work is involved; and (C) Satisfactory
assurance that the requested reproduction will be used only in connection with the specified litigation.
18 U.S.C. §1001. Statements or entries generally.
(a) Except as otherwise provided in this section, whoever, in any matter within the jurisdiction of the executive, legislative, or judicial branch
of the Government of the United States, knowingly and willfully
(1) falsifies, conceals, or covers up by any trick, scheme, or device a material fact;
(2) makes any materially false, fictitious, or fraudulent statement or representation; or
(3) makes or uses any false writing or document knowing the same to contain any materially false, fictitious, or fraudulent statement
or entry;
shall be fined under this title or imprisoned not more than 5 years, or both.
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