Revised 12/04/02 Exhibit “D-1” Exemption Form
STATEMENT BY ATTORNEY
CLAIMING EXEMPTION OR DISQUALIFICATION
CRIMINAL FELONY, MISDEMEANOR OR JUVENILE
(File annually by October 1
st
)
NAME: ________________________________________________________ BIRTH DATE: _______________
BUSINESS ADDRESS: _______________________________________________________________________
HOME PHONE: _________________________ BUSINESS PHONE: _______________________________
FAX NO.: ____________________________ E-MAIL ADDRESS:_________________________________
BAR CARD NO.: ______________________________________
__________ I am exempt from accepting any criminal felony, misdemeanor or juvenile appointments
because I am employed by a governmental agency, which is: ______________________.
__________ I am not qualified to accept criminal appointments and have not received any federal
appointments in the last 2 years.
__________ I am not engaged in the active practice of law.
__________ I am over 70 years of age.
__________ OTHER: _______________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
__________ I am qualified to take misdemeanor and juvenile cases but have paid into the “Laredo
Plan”.
By my signature, I attest that the information I have provided in this application is true and accurate.
_______________________________________________ ___________________________________
(Signature) (Date)
SUBSCRIBED AND SWORN TO before me the ________________ day of ______________________, 200 __.
___________________________________________ ___
Notary Public
______________________________________________
Type or Print Name
