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Court Appointed Counsel List Form
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Description
SIXTH DISTRICT COURT OF APPEALS COURT APPOINTED COUNSEL LIST FORM Please include my name on the court-appointed counsel list. I will accept appointments in the following areas: Criminal Juvenile Parental Rights Termination NAME___________________________________________________________________ SUPREME COURT IDENTIFICATION NO.____________________________________ ADDRESS________________________________________________________________ TELEPHONE NO. _____________________ FAX NO. __________________________ E-MAIL ADDRESS: PREFERRED COUNTIES: Erie Williams Fulton Wood Huron Lucas* Ottawa Sandusky *In order to be appointed to appeals in Lucas County, you must submit a current certificate of malpractice insurance with this form. CERTIFICATION: I certify that I have reviewed Ohio Administrative Code 120-1-10 and I will accept appointments as provided by this section. I further agree to inform the Court if I am not qualified within OAC 120-110 to accept a certain category of appointments. (http://codes.ohio.gov/oac/120-1-10v1). ________________________________________ Attorney Name _________________________________________ Signature Please return the completed copy of this form to the Court Administrator, Ohio Sixth District Court of Appeals, One Constitution Ave., Toledo, Ohio, 43604, or return by fax (419-213-4844), or e-mail (6thca@co.lucas.oh.us). _________________________ Date American LegalNet, Inc. www.FormsWorkFlow.com
