Attorney Grievance Committee Supreme Court, Appellate Division
First Judicial Department
180 Maiden Lane
New York, New York 10038
(212) 401-0800
[email protected]

Notarized Disciplinary History Request / Background Check Form
No Fee Required

For administrative purposes, the New York court system is divided geographically into four judicial departments and 13 judicial districts. The First Judicial Department includes districts 1 (Manhattan) and 12 (Bronx); the Second Judicial Department, districts 2, 9, 10, 11 and 13; the Third Judicial Department, districts 3, 4 and 6; and the Fourth Judicial Department, districts 5, 7 and 8.

Instructions

  1. This disciplinary history request form is for attorneys who are admitted, or whose offices are, or were at one point, located in the First Judicial Department ONLY. If you were admitted in another Judicial Department, and since admission you have never registered in the First Judicial Department, you cannot use this form. Contact your department of admission grievance committee to obtain a letter.
  2. Please email your notarized request in PDF form (no pictures) as an attachment to:
    [email protected]
    Subject: Background Check Clerk – [Type your name in Subject Line]
  3. We will reply by email only. Hard copy will not be provided.
  4. All fields must be completed. If you omit any information, it may delay a reply.
  5. The information in this form must match your attorney registration information. If there are changes, please update your attorney registration first before submitting this form.
  6. Requests without notarization will be rejected. We are presently accepting remote notarizations and your request must clearly state if the notarization was done in person or via video conference. Please note that as of 2/1/2023, there are new rules for New York notaries who notarize remotely.
  7. You will be responsible for forwarding our email response with attachments to third parties.

Authorization and Release

I hereby authorize the Attorney Grievance Committee, Supreme Court, Appellate Division, First Judicial Department, to release and provide information about my full disciplinary history, including, but not limited to 1) private and/or public discipline, 2) pending investigations, 3) complaints closed after an investigation, and 4) matters referred to another grievance committee or agency, if any, directly to me via email. I intend to forward the information to third parties.

Title
Your Signature

 

Notarization

Notarization Type

On the         day of                               in the year               before me, personally appeared                                       , personally known to me, or proved to me on the basis of satisfactory evidence, to be the individual whose name is subscribed to the within instrument and acknowledged to me that he/she executed the same in his/her capacity, and that by his/her signature on the instrument, the individual executed the instrument.

Name of Notary:
Signature of Notary:
Notary Stamp/Seal

 

This web version is for drafting only. You must print, sign, have it notarized, and email a scanned PDF to [email protected] following the above instructions.

(Rev. 2023.09.22)