Claim # _____________
The Lawyers Fund for Client Protection
of the State of New York

Application for Reimbursement

Answer every question on this application. If space is inadequate, attach additional pages.

It is important that you submit all evidence that proves your loss, such as canceled checks,
receipts, letters, closing statements, etc.

Print and mail the completed application to:
The Lawyers Fund for Client Protection - 119 Washington Avenue - Albany, New York 12210

1. Your Name and Address: Mr. Mrs. Miss Ms.
Age(s): ______ ______


Home Telephone:Social Security #:
Business Telephone:Occupation and Employer:

2. Name, address and telephone number of the attorney who has dishonestly taken your money or property:

3. What legal services did you ask this attorney to perform for you?

4. How much did you pay this attorney?

5. Was your agreement with the attorney in writing? Yes ___ No ___. If Yes, attach a copy of the agreement.

6. Did your loss involve: money securities other property? Specify:

7. State the amount of your loss:

8. State the date when the loss of your money or property occurred:

9. State the date when you discovered your loss, and how you discovered the loss:

10. Describe the attorney's dishonest conduct, and provide the name and address of a person who has knowledge of the loss:

11. This loss has been reported to:

District AttorneyBar Association
PoliceAttorney Disciplinary Committee
Furnish a copy of your complaint, and describe what action was taken.

12. Can your loss be reimbursed from any other source, such as insurance, fidelity bonds or surety agreements?
Yes ___ No ___ Don't Know ___. If Yes, describe this source:

13. Describe what steps you have taken to recover the loss directly from the attorney, or any other source:

14. State other facts that you believe are important to the Fund's consideration of your claim:

15. How did you learn about the Lawyer's Fund for Client Protection?

16. Name, address and telephone number of your present attorney:

I (We) verify and affirm, under penalty of perjury, that the information provided in this statement of claim is true

Signature of Claimant

Signature of Claimant