BEFORE THE LAWYER DISCIPLINARY BOARD
2008 Kanawha Boulevard, East
Charleston, West Virginia 25311
(304) 558-7999 Telecopier (304) 558-4015

Date: ________________________

1) Complainant:

Mr. (  ) Ms. (  )_____________________________________________________________
                                                        First                  Initial                  Last

Your Address: ____________________________________________________________
                                                        [Street/Post Office Box]

_______________________________________________________________________
                [City]                                              [State]                                  [Zip]

Your Telephone: [Home] ______-_______-_______      [Business] _____-_______-_______
[Note: It is very important that we have your telephone number(s)]

2) Attorney Being Complained Of:

Name: __________________________________________________________________
                    [First]                          [Initial]                                          [Last]

Address: ________________________________________________________________
                        [Street/Post Office Box]

_______________________________________________________________________
                [City]                                              [State]                                  [Zip]

Attorney's Telephone Number: ________-________-________

3) Have you ever filed a complaint about this matter here or anywhere else?

Yes [ ] No [ ] If yes, please explain: __________________________________________________

4) Have you brought a civil or criminal action against this attorney:

Yes [ ] No [ ] If yes, please explain: __________________________________________________

5) What kind of case or legal matter are/were you and this lawyer involved in?

____________________________________________________________________________

6) DETAILS OF COMPLAINT: [Write here or attach separate written explanation; attach copies of documents which help explain your complaint. Give date last unethical act occurred.]

____________________________________________________________________________

____________________________________________________________________________

____________________________________________________________________________
(DETAILS OF COMPLAINT CONTINUED)

7) OATH OF COMPLAINT: The facts written above, and in attached letters and documents are known by me to be true or are believed to be true.

                                                                            ___________________________________
                                                                                                Signature

Subscribed and sworn before me this ________ day of _________________________, 20____.

                                                                            ___________________________________
                                                                             Official signature and official seal of notary