FORM LS
: 01/2019 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 to:
Records Research and Certication Section, U.S. Copyright Oce, P.O. Box 70400,
Washington, DC 20024
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a copyright registration of published or unpublished works in the custody of the Copyright Office will be granted only when one of the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.
