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Attorney Change of Status Request Form

Name *

Attorney Bar ID # *

Reason for Requested Change * -Select-ActiveInactiveRetiredDeceased

Date Effective *

Month MonthJanFebMarAprMayJunJulAugSepOctNovDec

Day Day12345678910111213141516171819202122232425262728293031

Year Year20242025

Office Name if Applicable

Mailing Address *

City *

State *

Zip *

Phone Number *

Email Address *

Attorney Signature: s/

Date

Month MonthMay

Day Day1

Year Year2025

Representative Signature: s/

Relationship to Attorney

Date

Month MonthMay

Day Day1

Year Year2025

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