In the
Indiana Supreme Court

IN THE MATTER OF 	)	 
				)
The Appointment of 			)
				)	Supreme Court No.  
a Judge Pro Tempore			)		 
				)		
for the County  Superior/Circuit Court 	)		 

VERIFIED PETITION FOR APPOINTMENT OF JUDGE PRO TEMPORE 
PURSUANT TO TRIAL RULE 63(B)

	The Honorable Name, Judge of the County  Superior/Circuit  Court, petitions this Court for the appointment of a Judge Pro Tempore pursuant to Ind. Trial Rule 63(B). In support of the request, Petitioner represents to the Courts that:

1.	Petitioner is the duly elected holder of the office of judge of the County  Superior/Circuit Court.

2.	Petitioner will be unable to perform the duties of the office from Month Day, 20xx, because of Petitioner’s absence due to reason for need for Judge Pro Tempore, e.g. medical leave, active military service, etc...

3.	Documentation supporting petitioner’s request for the appointment of a Judge Pro Tempore is attached hereto.

	Wherefore, Petitioner respectfully requests the Court to appoint a Judge Pro Tempore until such time as Petitioner is able to resume the duties of the office.

	I affirm, under the penalties for perjury, that the foregoing representations are true.

	Dated this ______ day of _______________, 20____

							________________________________________
							
							Judge, County  Superior/Circuit Court