| Your
Name |
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| Your Email Address |
|
| Contact Phone
|
|
Contact Fax |
|
| Victim's
(Plaintiff's)
Name |
|
| |
|
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|
Lawsuit / Case Information Worksheet
|
|
| Type of case
you have |
Auto
Related
Drug
Related
Product
Liability
Wrongful Death |
Construction
Related
Medical
Malpractice
Workers
Compensation
Other |
| Victim's
Occupation |
|
Date of Event |
|
|
Is the Plaintiff able to work? |
Yes
No |
|
|
| Name of
Attorney |
|
| Attorney's Email |
|
| Attorney's Phone |
|
|
|
| Name of Law
Firm |
|
| Describe the
nature of your case, the amount of funds requested, and why
you are seeking funds. |
|
| |
|
|
|
|
Please answer the math
question. The sum of 9 + 3 = |
|
|
| |
|
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|
|
