Refusal to Contract with the Accused as an
Attorney and Counselor-at-law

I,        , being an Attorney and Counselor-at-law, do hereby sign this Notice confirming that I will be unable to provide Assistance of Counsel as secured in the Sixth Amendment and the Judiciary Act of 1789 Section 35 to the Accused.

And further, I ___ will / ___ will not disclose the reasons for being unable refusing to provide Assistance of Counsel to the Accused as secured in the Sixth Amendment and the Judiciary Act of 1789 Section 35.

I have ___ attached / ___ have not attached to this Refusal the reasons why I am unable to provide Assistance of Counsel as secured in the Sixth Amendment to the Accused.

Date: __                                 __

Signature of Counselor