Return Form to:
     PLJCC
     14300 Gallant Fox Lane
     Suite 123
     Bowie, Md. 20715

1. Print your name:

2. Address:

3. Telephone number:

4. The Name of the Attorney(s) and/or Judge(s) against whom you wish to file the complaint:

5. Address of Attorney(s) or Judge(s):

6. Telephone Number(s) of Attorney(s) or Judge(s):

7. Describe in Full Detail the Facts of your Complaint, including the Name of the Court, Address of the Court, Number of the case, Title of the case, Date of the case. Use the back of form and separate piece of paper, if necessary.

* YOUR COMPLAINT MUST BE SWORN AND SIGNED BEFORE A NOTARY PUBLIC.

My complaint is as follows (please number each page and initial):

I here by affirm and declare freely and without any reservations the following:

1. That I relinquish forever any and all rights including but not limited to privacy, ownership, and publication rights that I may have related to my sworn statement to the people's lawyer - Judge complaint Commission. (PLJCC)

2. That the PLJCC or its representatives may freely disseminate without any restrictions or reservations my sworn statement and excerpts thereof for public view at any time.

3. That public viewing and dissemination of my sworn statement may be in any public media without exception or exclusion, including the Internet.

4. That I will hold the PLJCC and its representatives blameless and harmless from any liability that may occur related to the disclosure and dissemination of my sworn statement.

Your Signature

Notary Public