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| TO: | THE GRIEVANCE COMMITTEE | OFFICE USE ONLY |
| THE NORTH CAROLINA STATE BAR | FILE NUMBER | |
PO BOX 25908 RALEIGH, NC 27611 TELEPHONE: (919) 828-4620 |
I, the undersigned hereby complain against (Name of Attorney) (Address) (City) NC (Zip) a practicing attorney of County. I agree to cooperate by furnishing to the representatives of the North Carolina State Bar all pertinent information and records in my possession concerning the alleged misconduct of said attorney. I further agree that if a hearing or inquiry is ordered concerning the alleged misconduct of said attorney, then I will furnish evidence concerning the facts by submitting to deposition or personal attendance at the hearing or inquiry. I hereby indicate that this information is provided and transmitted by me to the North Carolina State Bar for the purpose of investigating the alleged misconduct of the above- named attorney. I understand that I may also need to reveal this information to a privately-retained attorney to pursue private remedies on my behalf. I further understand that the immunity granted by North Carolina General Statute 84-28.2 applies only to those statements made without malice and intended for transmittal only to the North Carolina State Bar.
I also understand that the North Carolina State Bar may reveal this information to the accused attorney for his response to a formal inquiry and to others pursuant only to the Rules and Regulations of the North Carolina State Bar.
Name of Complainant
Mr., Mrs., or Ms.
(Please circle correct TITLE and TYPE or PRINT legibly)
Signature of complainant
Address
THIS AFFIDAVIT SHOULD BE NOTARIZED
City State
Zip
Sworn and subscribed before me this the
Home Telephone ( )
day of , 20 .
Stay Connected
Work Telephone ( )
(Notary Public)
My commission expires
DESCRIPTION OF YOUR COMPLAINT
NOTE: In the space below, tell us what your complaint is about. Be sure to include all facts that you want the State Bar to consider, including names, dates, and places. Use additional sheets if necessary. Attach copies (not originals) of any papers that support your complaint.
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