If your claim seeks a refund of legal fees, you must provide the Fund with the facts in this statement. Answer every question. If a space is inadequate, attach additional pages.

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

If you have your legal file, send it to the Fund. We will return it to you. If you do not have it, your local Attorney Disciplinary Committee may be able to locate it for you.

You should also understand that the Fund is not permitted to compensate for an attorney's malpractice or neglect; or to resolve fee disputes. the Fund can only reimburse money, securities or property that are wrongfully taken in the practice of law.

1. Name of attorney complained about:

2. When did you retain this attorney?

3. What legal services, or what type of legal case, was involved?

4. What was the agreed legal fee to be? $__________

5. How much of the legal fee did you pay? $__________

6. Did you pay court costs or filing fees in advance? Yes___ No___
If Yes, how much? $__________

7. How many times did you meet with this attorney? Briefly describe each meeting and what happened:

8. Describe all telephone calls with this attorney that involved a discussion of your case:

9. What legal papers did this attorney prepare for you?

10. Describe all court appearances this attorney made for you:

11. What is the status of your case at this time?

12. Do you have a new attorney to complete your case? Yes___ No___
If Yes, give the name and address of your new attorney:

13. What legal fee is your new attorney charging you to complete your case? $__________
How much have you paid?

14. Have you sent us your legal file? Yes___ No___
If No, please explain:

15. Have you sent us copies of receipts for legal fees paid, canceled checks, etc.? Yes___ No___
If No, please explain:

16. Please offer additional facts concerning your loss that you believe are important: