Department of Homeland Security (DHS) Of?ce for Civil Rights and Civil Liberties Civil Rights Complaint Fillable Version (last modi?ed 3/15/20?! 1) The purpose of this form is to assist you in ?ling a civil rights/civil liberties complaint with the Department of Homeland Security (DHS) Of?ce for Civil Rights and Civil Liberties (CRCL) regarding DHS programs and activities. This form is not intended to be used for complaints about employment with DHS. You are not required to use this form to ?le a complaint; a letter with the same information is sufficient. However: if you file a complaint by letter, you should include the same information that is requested in the form. CRCL Mission: .7 The DHS Office for Civil Rights and Civil Liberties (CRCL) supports the Department as it"secures the nation while preserving individual liberty, fairness, and equality under the law. We investigate claims of 7 civil rights and civil liberties abuses, to help DHS improve protections and programs. Do you have a DHS civil rights or civil liberties complaint? if you believe that DHS personnel or a DHS program or activity has violated your rights, we want to hear from you. Fill out this form, or write, us an email or letter. - i In connection with a DHS program, activity, or policy, have you experienced: - Discrimination based On your race, ethnicity, national origin (including language proficiency), religion, gender, or disability? (Note: do not use this form to make a complaint about employment discrimination; see - Denial of meaningful access to DHS or DHS-supported programs, activities, or services due to limited English pro?ciency? - Violation of your rights while in immigration detention or as a subject of immigration enforcement? Discrimination or inappropriate questioning related to entry into the United States? a Violation of your right to due process, such as your right to timely notice of charges or access to your lawyer? I . . Violation of?the Violence Against Women Act's confidentiality requirements? a Physical abuse or any-other type of abuse inflicted upon you? Any other civil rights or civil liberties violation related to a DHS program or activity? Notes on Confidentiality and Anonymity: A) You may remain anonymous by not filling in your name, below. However, CRCL may not be able to investigate your complaint unless you provide enough information to conduct an investigation. B) Disclosure of the information you provide, including your identity, is on a "need-to-know? basis, and is discussed in the Privacy Statement at the end of this document. IF YOU CHECK THE BOX BELOW, WE WILL YOUR TO OTHER OFFICES, IN OR OUT OF DHS (unless it is necessary for investigation of criminal misconduct). Note, however, that this will in many situations make it very dif?cult or impossible, practically speaking, for us to investigate the allegations you raise. El i do NOT want CRCL to disclose my name to other of?ces, and understand this decision will often make it impossible for an investigation to take place. C) Reprise] against complainants to ORCL is unlawful; if you feel you have been a victim of reprisal, CALL US. 1-866-644-8360. Complaint information If you don?t speak/write English, CRCL has access to interpreters and can talk to you in any language. Information about the persOn who experienced the civil liberties violation (?ll in what you can) . Name; Angel Rosa First and Middle Last Phone #1 Cell: 203'901?8222 - Home; NIA Work; 646-648-1713 Please note that we may contact you at the provided numbers. Mailing Address: clo Thomas Rome Law Group, Attention: Thomas 8. Rome, Esq., 254 Prospect Ave, Hartford, CT 06106 City State Zip Email (Optional): thomas.rome@gmail.com; reidmark527@gmail.com . PO Box or Street address ?Date of Birth: 08/11/1960 Alien Registration (if you have one and it?s availableCheck here if you are in detention now. Which facility? Facility name Facility address 5 Check here if you are represented by an attorney in this matter. if so please provide the attorney?s name and contact information Thomas 5. Rome, Esq.,Thomas Rome LawGroup, 254 ProspectAve.. Harlford, CT 06106 lhomas.rome@gmail.com, 850-236-6951 Q) Are you filling in this complaint form on behalf of another individual? it yes, please provide your information. Name; Thomas 3- Rome. ESQ- Angel Rosa's attorney First Last Job title Organization many): Thomas Rome Law Group Phone Cell: 6466484713 Home: Work: 360433-5951 Maifing Address: 254 ProspectAve., Hartford, CT 06106 PO Box or Street address Cihr State Zip What happened? Describe your complaint. Give as much detail about your experience as possible. Angel Rosa was arrested by ICE and incarcerated in the Utah County Jail, just south of Salt Lake City in Spanish Fork, Utah, on immigration detainer. The facility has a contract with ICE. In December 2014, guards put him in a cell with a broken toilet that overflowed with feces, and didn?t allow Mr. Rose to shower. He was then placed in solitary con?nement as punishment for the broken toilet. At some point during this time, Mr. Rose caught an infection known as Fournier's gangrene. It began in his testicles. Left untreated, it eventually caused his rectum to swell shut, and his intestines became infected. Mr. Rosa does not speak English. Only after another inmate, who spoke English, told a guard about Rosa?s urgent medical situation was he examined and taken to an outside hospital. Mr. Rosa claims he was told to sign documentation so that, if needed, doctors could surgically remove his testes. Ultimately, he was not castrated, but he says he was left sterile and placed on antibiotics and other medicine. Fournier's gangrene is caused by both aerobic and anaerobic bacteria. It has an overall mortality rate of 40%, higher in the presence of sepsis. Too sick to remain in detention, Mr. Rosa was released under terms that included regular check-ins with immigration authorities and for him to wear an electronic monitoring device on his ankle. For the past year, he has tried to comply with these conditions in good faith, but authorities disagreed. Mr. Rosa was taken back into ICE detention on or about January 15, 2016, awaiting removal. His current detention location is officially undisclosed by ICE, perhaps because ICE wishes to avoid media scrutiny of his case. Continue on an additional page, if needed. When did this happen? If ongoing,please indicate when the problem began. ma happened on more than one date, list all dateS): Mr. Rosa's inhuman treatment at ICE's hands took place in late 2014 and early 2015, at the Utah County Jail in Spanish Fork, Utah. It is pertinent that on July 12, 2014, ICE records show that another detainee, Santiago Sierra?Sanchez, a 38-year?old Mexican national, died after he was detained in the Utah County Jail. The cause of Mr. Sierra?Sanchez's death was determined to be staphylococcus aureus infection. He died at the Utah County Region al Medical Center, bUt he had been held previously at Utah County Jail before he was taken there. Where did this happen? Place (for example, name the detention facility airport, other)" City; Spanish Fork State or Country: Utah. USA Who treated you unfairly? An employee, contractor, or officer of (check as many as apply): Citizenship and Immigration Services (USCIS) 7 Customs and Border Protection Not sure which DHS Of?ce CUStoms Of?cer I employee working under the authority Border Patrol Agent of DHS 287g of?cer) Federal Emergency Management Agency Specify: (FEMA) Immigration and Customs Enforcement Secret Service Transportation Security Administration US. Coast Guard (USCG) Other DHS program (specify) *If your complaint is about an incident at an airport, train station, or border crossing, you may also file a complaint with the Department of Homeland Security?s Traveler Redress Inquiry Program (TRIP). TRIP and this Office will review your complaint together, resulting in a faster response. Go to: ?List anyone else-who may have seen or heard what happened. (if you do not know their names, provide whatever details you can) Names (or other information, agency): Mailing Address: PO Box or Street address City State or Country Zip Phone No.: Email: Names (or other information, agency): Mailing Address: PO Box or Street address City State or Country Zip Phone No.: Email: Continue on an additional page, if needed. Have you contacted any other DHS component or other federal, state, or local gbvernment agency or court about this complaint? El Yes: Agency/Of?celCourt Date: No If so, has anyone responded to your complaint? El Yes El No if Yes, describe what has been done to respond to your complaint: Continue on an additional page, if needed. (3 Is there any other information you want us to know about or consider? On information and belief, Mr. Rosa is scheduled to be removed by ICEVfrom the United States on Wednesday, February 3, 2016. We are requesting an immediate stay of his removal on humanitarian grounds and until further investigation of the instant complaint. If Mr. Rosa is removed to Guatemala, he will face near impossible odds of survival -- almost certain death because of his medical condition caused by lCE's negligence, gross negligence, or other inhumane neglect. He will be unable to take care of himself, to acquire absolutely necessary medical care for his potentially fatal disease contracted while in ICE custody, nor required medications, nor even adequately sanitary housing. ContinUe on an additional page, if needed. If you are not proficient in English, please indicate the language in which you prefer we communicate with you. (9 If you have problems understanding this form or any other question, contact CRCL: E-mail: crcl@dhs.gov By US. Postal Service: Phone: Local: 202-401-1474 or Department of Homeland Security Tort Free; 866-644-3350 CRCL/Compliance Branch TTY: Local TTY: 202-401-0470 245 Murray Lane. SW - Toll Free TTY: 866-644-8361 Building 410. Mail Stop #0190 Fax; 2024014708 Washington, DC 20528 Note: Because of security measures, it can take up to 4 weeks for us to receive US. mail. To submit this form by email, please save, attach, and Send to crcl@dhs.gov. Please attach or send all information that supports your complaint, such as documents, photos,'medical records, grievances, or witness statements. Submit copies, not originals; put your name and the date of this complaint on each document. (Fax to: 202-401-4708, or email scans of your documents to crcl@dhs.gov, or mail to the address listed above.) Keep a copy of this complaint for your records. Privacy Act Statement Under 6 U.S.C. 345 and 42 U.S.C. 2000ee?1, the Office for Civil Rights and Civil Liberties (CRCL) is authorized to investigate compiaints and information from the public about possible vioiations of civil rights or civil liberties related to DHS employees, programs, or activities. A federal law, called the Privacy Act, says we must explain how we protect your information while processing your complaint. If your complaint is more appropriately handled by a different federal office, we will refer it to that office. in order to investigate your complaint, CRCL will disclose the information regarding your cemplaint to other appropriate DHS offices, including the Of?ce of the inspector General. CRCL may also disciose certain information from your complaint if we are required there?is no privacy impact. For example, we send reports to Congress every three months about complaints submitted by the public. Those reports describe the types of complaints, and do not include personal information. To read our past reports, go to To learn more about the Privacy Act go to the Federal Information Center, You may use the following pages to include additional information about your complaint if needed. Please specify which num berls) above you are continuing. (3 James D. Mathews, DO Providence Family Medicine 382 West 280 North PO Box 609 Providence, Utah 84332 Of?ce :435-752-0330 Fax 435-755?0922 14 September 2015 From: James Mathews Re: Angel Rosa, DOB 8/11/1960 To: Whom It May Concem I am writing this letter on behalf of Angel Rosa. I am his doctor. I have been treating him for high blood pressure (for which he takes Lisinopril), high cholesterol (for which he takes Zocor), diabetes mellitus (for which he takes Metformin), and a groin testicular infection which has recurred several times, and at one point required hospitalization and surgery this year. He has had several recurrences of the infection. He sees me for maintenance exams, and for rechecks on his diabetes. He is currently undergoing an evaluation for severe headaches and tingling on his face. I am not sure of the cause, as we are trying to discover this. I have ordered an MRI of his brain to check this. It is in my professional opinion that he should remain where his family and medical cares are available, speci?cally in the Cache County, Utah area. Thank you for your consideration. Very Respectfully, James Mathews Data df Service 12;.2422314 '1 - Reason for visit. Telephone Staff Tay'ler Gsifey. RN Allergies 'ana: noted. on . Dzh?er specified camp?catluns?m?t?n? I 49114312 I 7 I. - Int 542503513 Legaxh ta! Rosa?ngel $111196!) Gender . . . . . THERAPISTS PROGRESS NOTE Pagaiafz Nurse Quay Visit I Beans Surgical 12124i2G1-i Diagnasis Other speci?ed complicatiens of precedurES net elsewhere classified Refated anti absc?ss Reported {late 9? Onset Bate Frabfem was Noted friam Pro?t-Em. '(ScaiPe?w??und Clean?er NS ?nd Drape-to peri-Wourid I I. 7 Fiiler VAC-Sponge. Dressing Vac~sponge and Vac?psite Freq?ency Shree times per week Duratict?e cne week Date rapt)? printed: 12/24/2014 3:53:33 PM Pageiofz Page? of 3 Date Problem wee Noted nemesis Problem Status Exudate Tissue lose Wound bed Perlwotind Granolatlon Pain from Problem Measurement VIEEATMEFET Filler Bragging Frequency Duration THERAPIST CGMMENTS INS antt new; Draoe to pinininagin? . none -w I ?own,? ntermoun in 542508513 Lag-Ear: Ragtim?ai pitai Rose,Angel an mono Gender .. . THERAPISTS PROGRESS NOTE EROBLEM: lnlounoE other specified oompli?atione, serotom I Reported beta of Goeet 12/1l2l114 Signs Surgical 12,246?2614 Diagnosis Other specifieti complications of procedures not elsewhere classified Related Celtu?tls and abscess The prohlem is generally described as inadequetely nontrolled. I I minimum amount of eerosenguinous exudate foil-thlokness wound with exposed Subcutaneous I has beefy red granulation normal 103% 2 (Scale $3.5 orn 91.8?5 omat VAC-Sponge Veo~sponge and VecOpsile three times per week one week Patient comes to clinic with wound vac intact. Daughter is present with pt today. Pt does not speak any English. interpreter services were called but because of holiday no one answered. Daughter speaks English and le able to interpret for on today. Daughter can not remember the hospital he had surgery at. She states that he had surger a few weeks ago for an infection. She states he has a home care nurse outdoesn't know the agency name She states she will call us when she finds outs what company they are from so we can send orders. Daugther etates pt is taking diabetes medication. and abx and pain medication. She doesn?t know the names of them right now. Wound veo was plaoeti. Pt to flu in one week end call us once they know the hometieelth agency name. Daughter veroelizecl understanding of instructions. Decrease the level of pain. increased granulation tleeue form uletlon. infection control. Decrease the amount of necrotic tissue. Absorb drainage. Contraction of wound margins, Complete healing. Eoithellelization of wound tied; Date report printed: 12IZ4IZOT4 12:53:24 PM . v. A r-ra H, .aq? - . Vania. Page .3 of 8 Date oi Service: Otio4l2015 CHJEF COMPLAINT: Abdominai pain. OF PRESENT This? 54-year-old mate. was: brought to the emergency department by his wife and daughter with somewhat of a complicated and mnvotuted history. He was apparently incarcerated in orioon and had a surgery done at a hospital in the Provo area. where he spent 15- ciays in the, hospital, he had a signi?cant infection of the scrotum that required fairly extensive surgery. Description of tho process and that he possibly may have had Foumlor gangrene, in any coco. he now is currently having wound care toiiowup by Dr.- Nail here at the wound oiinic at Logan Rogionai Hospital. He has a worrnd VAC in place on the wound in the sorotum. He is concerned because he ran out of pain medicine 3 days ago and has been having worsening pain and he explained it is 10110 in severity, primarily in the tort inguinal region. radiating throughout hi3 entire abdomen. He has itching around the edge of his wound VAC. This Surgery occurred about a month ago. ho has had some subjective fevers with no objective measurement. has felt a littlo bit constipated welt. He has been on naroottc pain medicallon that ho is currently ran out of. Ho has homo hcaith nurses come in to his homo to do daiiy dressing changos and wound management with the wound VAC in piaoo. He notes no consistent alleviating factors to this 10/10 severity pain, it is achy in quality. He is worried that the infection is stiit in his body causing these issues. hora are no other-concerns or complaints at this time. Spanish translation was utilized in communication with the patient. CURRENT See the: EMR. whioh is reviewed and agreed with. See tho EMR. which is reviewed and agreed with. PAST MEDICAL Sea tho EMR, which is reviewed and agrceowith. OF SYSTEMS: See the, EMR. which is reviewed and-agreed with. FAMILY AND SOCIAL Patient resides in Hyrurn. Utah. He has a past history of tobacco use. PHYSICAL EXAMINATIGN: VITAL, Temperature 36.33. guise 82, reSpirations 17'. blood pressure 129/84. oxygen saturation 95% on room air; Pain 10ft 0. GENERAL: The patient is awake, interactive, and in no acute distress. HEENT: Head is normoocphaiic. Scterae are anictaric. Extraocular muscles are intact. No nasal discharge! noted an exam. NECK: Seemingly supple with normal range of motion. Logan Regional Hospitai ROOM: a .A ED PhysicianiLlP Report 571295545 MRN: 18.224? ENC: 49162449 Prinlod on 072112015. at 14:43 Page 1 of 3 DOB: AGE: 54YAgoF-2Daiu OiHotc Name: ROSA, ANGEL ANTQNIO {authored DURFEE. BRANQON Authored For: WHITTAKER. NATHAN D. Footer: Varsion i101 $5121.33 I personaliy examined and evaluated this pa?enh reviewed pe?inent data, and dimmed {ha care given. I was present for the key pnriions of any procedures- perfca assessment. and plan as ascended. I aI given in this patient. Daiegh. I Tim 31% . rmed by Brandon Durfee, PAC. under my supawIsIan. i agree with {he ?ndings, 50 supervised anyia? IV infusions?njections 88163 VID: TED: 9616255 D: 0110812015 01 32633213 011088015 03:03:14 Authared 3y: BRANDON BURFEE, PM: Authored For: D. MD Elemmnicaily Signed By: NATHAN D. WHITTAKER. MD (0110915 {03:95)} Logan Regional Haspitai ED PhysicianlLIP Report EMPI: 52?1295645 MRN: 18-2247 ENC: 49152449 4x .?Z?f??rnmlaln Jr! P??cd on 0731120155 n! 14:48 RQGM: D38: AGE: 5435199 AI mm mm Hame: ROSA. ANTONIO Authored By: DUHFEE. BRANDON Authored For: WHITTAKER, NATHAN B. :ooter' Vors'rau CI 01 (Ed? 1:113 Page 3 0f 3 Patient: Arrival Method ?eperture Diapositlon Departure instructiuns S?peciai Needs Pain Aesessment Loeatieu Current Levei Current Regimen Geeie . . 49114312 I etvgg. r11: un - i 542508613 i Rese,Angei Bit 1/1963 Qen?er I THERAPISTS NOTE Pageant: .. t. Ambulatbry Departure with eseistenee Special needs, Compiex discharge instruettene (detailed with and Patient Processing: Complex Language barrier scretum 0 Scale 0 pt in comfortebie positien in exam chair. Tepieei iidecatne placed on weund bed. pt it} tolerate dressing change and preceduret 1253912014 3:28:49 AM Teyter Bailey, RN 12130f2i314 9:31:16 AM Justin White, CHRN Charlie? from HH called and gave me information on the patient. They ere the ones caring for patient. She stated that he is a recent diagnosed diabetic. He recentiy was in prison and was release due to this infectien and surgery that he has hadt She states she went over his medication and he is eniy taking metierrnin and giimebiride. She state-5 there was no ebx that he was taking that she eeutd rind. Transieter wee present tedey. Mike. Patient and daughter present through entire visit. Gave patient list of accepting primary physician-3 in our facility and contact informatien for pt it: setup a primary care MD. Ali questions and cencerne were resolved and pi denied any furhter questions or concerns at this time. Date repart printed: 1333132914 11:20:13 PM This patient was eiectronicatiy signed by . Justin White, CHRN at 1213912914 16:24:12 AM. .?rsmmu?thr?KA-?ui??n-I?J? -. at.? .u-uura Page 4 {if 4 Wound Care? ReportilZ/34I2?l4 {Statusr anaig Animated By: it: WOUND Authemd Fm: I8 WGUNE: Signed By: EC WGUNE {12E4f213?t4 13:16} Megan Regional Hospital ~x In Wound Care Report EMPI: 571295545 MRN: 13-2243 ENC: 491i4812 P??i?d on at $4 #9 HQQM: 303: AGE: 54YAga AI Daio $124955 ?ame; ROSA. ANGEL ANTONIO Authored By: Authoi'ed Fur: WOUND. EC Frauen Version Page?! of 3 ,1 Notice of Entry of Appearance DHS as Attorney or Accredited Representative Department of Homeland Security Form G-23 OMB No. 1615-0105 Expires 03/31/2018 HV .-1 >l FamilyName ROME (Last Name) 2.b. Given Name Ehomas 2.c. MiddleName [gott 3'3' '254 Prospect Avenue and Name 3.b. Apt. 'Ste. Flr. 3.c. City or Town {Hartford 3.d. State 3,e. ZIP Code?sioe 3.f. Province 3.g. Postal Code 3.11. Country JUSA 4. Daytime Telephone Number ?8602366951 5. Fax Number 186023652 63 6. E~Mail Address (ifany) lthomas . rom?@gmail . com Mobile Telephone Number (zfany) r. This appearance relates to immigration matters before (Select onlyone box): La. [j USCIS List the form numbers - 2.a. . ICE 2.b. List the speci?c matter in Iwhich appearance is entered 3.3. CBP 3.b. List the speci?c matter in which appearance is entered I enter my appearance as attorney or accredited representative at the request of: 4. Select only one box: Applicant [j Petitioner [j Requestor I Respondent (ICE, CBP) 5.3. Family Name (Last Name) 5.1). Given Name (FirstName) lAngel 5.c. Middle Name ,7 4? 6. Name of Company or Organization (Ifapplz?cable) A: Form 03/04/15 In I Page 1 of 4 a 8. I Alien Registration Numb er (A?Number) or Receipt Number Daytime Telephone Number 10; Mobile Telephone Number (ifany) . I 11. \EI-Mail Address (ifcmy) n- in?: NOTE: Provide the mailing ad ress of the applicant, petitioner, requester, or respondent. If the applicant, petitioner, requester, or respondent has used a safe mailing address on the application, petition, or request being ?led with this Form G-28, provide it in these spaces. 12.21. Street Number and Name 12.10. Apt. Ste. [3 Flr. 12.c. City orTown 12.d. State 12.e. ZIP Code[ 121'. Province 12.g. Postal Code [i 12.h. Country memm._ Select all applicable items. La. . I am an attomey eligible to practice law in, and a 7 member in good standing of, the bar of the highest courts of the following states, possessions, teitritmies, commonwealths, or the District of Columbia. ([fyou need additional Space, use Part 6. Licensing Authority Pomecticut 1 1.1). Bar Number (zfapplicable) 3 2 5 Le. Name of Law Firm Law Offices of Thomas Rome 1.d. I (choose one) am not am subject to any order of any court or administrative agency disbarring, suspending, enjoining, restraining, or otherwise restricting me in the practice of law. If you are subject to any orders, explain in the space below. (If you need additional Space, use Part 6.) . 2.a. I am an accredited representative of the following quali?ed nonpro?t religious, charitable, social service, or similar organization established in the United States, so recognized by the Department of Justice, Board of Immigration Appeals, in accordance with 8 CFR 292.2. Provide the name of the organization and the expiration date of accreditation. 2.b. Name of Recognized Organization 2.c. Date accreditation expires Form 03/04/15 . . i' Page 2 of 4 3. I am associated with the attorney or accredited representative of record who previously ?led Form in this case, and my appearance as an attorney or accredited representative is at his or her request. NOTE: If you select this item, also complete Item Numbers La. Lb. or ItemNumbers 2.a. - 2.c. in Part 3. (whichever is appropriate). I am a law student or law graduate working under the direct supervision of the attorney or accredited representative of record on this form in accordance with the requirements in 8 CF 4.3. 4.b. Name of Law Student or Law Graduate -J area:initerate:antennae.. ., I have requested the representation of and consented to being represented by the attorney or accredited representative named in Part 1. of this form. According to the Privacy Act of 1974 and DHS policy, I also consent to the disclosure to the named attorney or accredited representative of any record pettaining to me that appears in any system of records of USCIS, ICE or CBP. When you (the applicant, petitioner, requester, or respondent) are represented, DHS will send notices to both you and your attomey or accredited representative either through mail or electronic delivery. DHS will also send the Form 1-94, Arrival Departure Record, to you unless you select Item Number 2.a. in Part 4. All secure identity documents and Travel Doctunents will be sent to you (the applicant, petitioner, requestor, or respondent) unless you ask us to send those documents to your attorney of record or accredited representative. FormG?28 03/04/15 If you do not want to receive original notices or secure identity documents directly, but would rather have such notices and documents sent to your attorney of record or accredited representative, please select all applicable boxes below: [3 Irequest DHS send any notice (including Form 1-94) on an application, petition, or request to the business address of my attorney of record or accredited representatiVe as listed in this form. I understand that I may change this election at any future date through written notice to DHS. I request that DHS send any secure identity document, such as a Permanent Resident Card, Employment Authorization Document, or Travel Document, that I am approved to receive and authorized to possess, to the business address of my attorney of record or accredited representative as listed in this form. I consent to having my secure identity document sent to my attorney of record or accredited representative and understand that I may request, at any future date and through written notice to DHS, that DHS send any secure identity document to me directly. . - CM). 3.3; Signature of Applicant, Petitioner, Requestor, or Respondeppw-s, (.- Kea? 3.1). Date of Signature I have read and understand the regulations and conditions contained in 8 CFR 103.2 and 292 governing appearances and representation before the Department of Homeland Security. I declare under penalty of perjtuy under the laws of the United States that the information I have provided on this form is true and correct. 1. Signature of Attorney or Accredited Representative 2. Signature of Law Student or Law Graduate 3. Date of Signature I ill Illil Page 3 of4 pertaining to Part 3., Item Numbers 1.3. - 1.d. Form 03/04/15 Page 4 of 4