Litigation Statement Form LS {LS}

4 UnitedStatesCopyrightOffice,CertificationsandDocumentsSection Litigation Statement · Form LS BASIC INSTRUCTIONS RequestforReproductionofCopies,Phonorecords,orIdentifyingMaterialDepositedinConnectionwithCopyrightRegistration Thisformmust beusedtorequestcopiesofcopyrightdepositspursuantto37CFR§201.2(d)(2)(ii).Thisformmust containanoriginalsignature andall informationrequestedinorderfortheOfficetoprocesstherequest.AseparateFormLSmustbeusedforeachworkrequested.The personwhopicksupcopiesmustpresentphotoidentification. warning:Materialrequestedmust only beusedforspecificlitigationnoted. 1 2 a Pursuant to 17 USC §706(b) and 37 CFR §201.2(d)(2)(ii), please make a copy of the deposit described below. Registration number Effective date of registration Title and description of this work: b a The copy of this material should be: Uncertified Certified (additional fee applies) Expedited (additional fee applies) The copy of this material is to be used for the following actual or prospective litigation: Name of client: Address: City: Phone: ( ) Fax: ( ) State: Email: Zip: b c Client is (or may become): Name(s) of other party/parties: Plaintiff Defendant Name of court if proceedings have been instituted: Nature of the controversy: Docket number: Caption: d If litigation is prospective, please give a full statement of the facts surrounding the controversy (attach additional sheets if necessary). Attach any letter or other document that supports your claim that litigation may be instituted. more on back · Completeallapplicablespaces(number3)onthereversesideofthispage. · Readallinformationandsignnumber4. American LegalNet, Inc. www.FormsWorkFlow.com DONOTWRITEHERE Page1of pages requested material was picked up by photo id checked by or mailed to date do not write above this line FORM LS for copyright office use only 3 Printed name of requesting attorney or pro se litigant: Name of firm: Address (no P.O. boxes) : City: Phone: ( ) Fax: ( ) State: Email: Zip: The requested material should be mailed to the address above will be picked up by: Individual'snameornameofmessengerservice Accountnumber use requesting patrons FedEx account: 4 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). Handwrittensignatureof Attorney: Barnumber Stateofpractice Date Proselitigant(individual serving as his or her own attorney) Returnthisformto: RecordsResearchandCertificationSection,U.S.CopyrightOffice,P.O.Box70400, Washington,DC20o24 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. form ls rev: 07/2013 Printed on recycled paper u. s. government printing office: 2013-xxx-xxx American LegalNet, Inc. www.FormsWorkFlow.com