AO 10A (Rev. 12/19)
REQUEST FOR EXAMINATION OF REPORT FILED BY
A JUDICIAL OFFICER OR JUDICIAL EMPLOYEE
In accordance with section 105 of the Ethics in Government Act of 1978, as amended, I request that the report of the
following named Judicial Officers or Judicial Employees be sent to me in electronic form. By checking this box, I am requesting
a paper copy rather than an electronic copy (See instructions).
NAME POSITION YEAR(S) REQUESTED
NAMES
OF
INDIVIDUALS
WHOSE
DISCLOSURE
REPORTS
ARE
REQUESTED
ORGANIZATIONS
OR PERSONS
ON WHOSE
BEHALF THIS
REQUEST
IS MADE
NAME ADDRESS
PROHIBITIONS
I understand that the statute makes it unlawful to obtain or use this or these reports for: any unlawful purpose; any commercial
purpose other than by news and communication media for dissemination to the general public; determining or establishing of
the credit rating of any individual; or use, directly or indirectly, in the solicitation of money for any political, charitable, or
other purpose (5 U.S.C. App. 4 § 105(c)).
I understand that whoever, in any manner 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 not more than $10,000 or imprisoned not more than five years, or both (18 U.S.C. § 1001).
I am aware of the prohibitions on the obtaining and use of this information, as are stated above, and that this request for
examination is a matter of public record.
PERSON
MAKING
REQUEST
Name: Occupation:
Phone Number: Email Address:
Mailing Address:
I certify under penalty of perjury that the foregoing is true and correct. (28 U.S.C. § 1746)
Signature Date executed
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Instructions for Requesting a Copy of a Financial Disclosure Report
from the Financial Disclosure Office
These instructions provide y
ou with the inform
ation necessary
to request a copy of a judge's or a judiciary employee's
financial disclosure report filed with the Administrative Office of the U.S. Courts in accordance with the requirements of
the Ethics in Government Act of 1978, as amended (Act) (5 U.S.C. app. §§ 101-111). Before a financial disclosure report
can be released, a Form AO 10A, Request for Examination of Report Filed by Judicial Officer or Judicial Employee, must
be completed. Each judge or employee whose report you request must be listed by name on the form.
The Form AO 10A may be obtained from the judiciary's website at www.uscourts.gov
or from the Financial Disclosure
Office. Questions concerning the completion of the Form AO 10A, or the report request process, should be directed to the
Financial Disclosure Office at (202) 502-1850, or by fax at (202) 502-2113.
Please note that section 105(b)(2)(A) of the Act requires that you provide your name, occupation, and address on the
Form AO 10A. Section 105(b)(2)(B) requires that if you are obtaining a report at the request of, or on behalf of, another
individual or an organization, you must specifically list that individual or organization in the appropriate block on the
form. Section 105(b)(3)(C) requires you to sign the request form indicating that you are aware of the prohibitions on
wrongful use as delineated on the form and in section 105(c)(1) of the Act. Failure to comply with these statutory
requirements is cause to deny your request. It is helpful to provide a phone number and email address where you can be
reached in case there is a question relating to your request.
All financial disclosure reports will be provided on an electronic storage device at no charge. If you wish to receive a
paper copy of a report, you must check the appropriate box on the Form AO 10A. The reproduction cost for a paper copy
of a financial disclosure report is $0.20 per page. The Financial Disclosure Office only accepts checks and money orders
for the exact amount provided to you. Your check or money order should be made payable to the Administrative Office
of the United States Courts. Paper copies of a report will not be mailed until payment has been received.
After completing the Form AO 10A, you must return the form to the Financial Disclosure Office, Administrative Office
of the United States Courts, Suite G-330, One Columbus Circle, N.E., Washington, D.C. 20544; email it to
CommitteeonFinancialDisclosure@ao.uscourts.gov (with Form AO 10A in the subject line); or fax it to (202) 502-2113.
Upon receipt of the Form AO 10A, each judge or employee will be notified that you requested his or her report, then a
copy of the requested report will be sent to you. If a paper copy is requested, you will be notified of the cost.