Claim # _____________ |
of the State of New York Application for Reimbursement |
Age(s): ______ ______ | ||
Name: Address: | ||
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.
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:
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:
Date |
Signature of Claimant Signature of Claimant |