DOJ-OGR-00023880.jpg

STATEMENT OF APPLICANT I certify that I am authorized to act as the legal representative of | who is a licensed member of the bar of the State of New ‘| or ¥ ‘ I request that I be allowed to interview and correspond with te Evstein , Federal Register Number__76316- 954 __, whois confined at the MDC/ MCC. I am aware of my responsibility as a representative of the above-named attorney and certify that I am able to meet this responsibility. I am also aware of the Bureau of Prisons’ Policy on Inmate Legal Activities and certify that I am able to and will adhere to the requirements of this policy. I pledge to abide by Bureau of Prisons regulations and institution guidelines. I hereby certify that all of the information contained in this questionnaire is true and correct to the best of my knowledge. Furthermore, I understand that all information contained in this questionnaire may be investigated and verified through the use of federal, state and local authorities. Applicant’s printed name: Applicant’s signature: Date Completed: 2014 Private Investigators must submit a copy of their Private Investigators Certificate and Private Investigator’s photo identification. Page 7 of 10 Revised 2/01/08 DOJ-OGR-00023880