United States District Court
Northern District Of Illinois
Form LR83.28. Declaration of Admissions to Practice Required by LR83.28(d)
DECLARATION OF ADMISSIONS TO PRACTICE
In Re _______________________________
Disciplinary No. ________
I, _________________________, am the attorney who has been served with an
order to show cause why disciplinary action should not be taken in the above
I am a member of the bar of this Court.
I have been admitted to practice before the following state and federal
courts, in the years, and under the license record numbers shown below:
I declare under penalty of perjury that the foregoing is true and correct.
Executed on __________________________
(Full name - typed or printed)
(Address of Record)
This declaration must be signed, and delivered to the court with the
attorney's answer to the order to show cause or any waiver of an answer. Failure to
return this declaration may subject an attorney to further disciplinary action.
Under 28 U.S.C. § 1746, this declaration under perjury has the same force and
effect as a sworn declaration made under oath.