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Type of Legal Help Needed: *
Zip Code: *
VID

Please Complete the Following:
Do You Currently Have an Attorney? *

Yes No
Total Monthly Income? *
Total Debt? *
Do You Own Real Estate? *

Yes No
Marital Status: *
Do You Have Children? *

Yes No
Value of Your Assets? *
Any Prior Alcohol Related Offenses? *

Yes No
Type of Alcohol Test Performed? *
Blood Alcohol Content Measured by Test: *
Status of Claim: *
Date of Incident: *

Year Month Day
When was the Alleged Crime Committed? *

Month Day Year
Were You at Fault? *

Yes No
Primary Injury: *

Anxiety Back or Neck Pain Broken Bones Cuts and Bruises Headaches Memory Loss Loss of Limb Other (describe on next page)
Cause of Injury: *
What is Your Role in this Matter? *

I have been accused I am acting on behalf of someone who has been accused Other
What Type of Charge? *
What is Your Current Country of Citizenship? *
Where Are You Migrating To? *
How are you Trying to Enter the Country? *
What Type of Immigration Issue? *
What is the Current Status of the Immigration Case? *
Where is the Person Seeking Immigration Located? *
What is the Applicant's Occupation? *
Age of Applicant? *
Does Applicant have a Long Term Disability Policy? *

No Yes
How Did Applicant Obtain the Disability Policy? *
Has Applicant Previously Applied for Long Term Disability Benefits? *

Yes, claim pending Yes, claim denied No
Has Applicant Ever Received Long Term Disability Benefits for this Claim? *

Yes, currently receiving Yes, appealing a decision to stop payment of benefits No
Applicant's Monthly Salary/Pay When Last at Work: *
When Did Your Condition First Begin to Affect You?

Month Day Year
Has Your Condition Caused You to Stop Working or Substantially Reduce Your Work Hours? *

Yes No
Have You Worked at Least 5 of the 10 Past Years? *

Yes No
Have You Applied for Social Security Disability? *

Yes, claim pending Yes, claim denied No
Are You Currently Receiving Social Security Disability Benefits? *

Yes No
Were You Hospitalized or Treated by a Doctor? *

Yes No
Was a Police Report Filed? *

Yes No
Total Employees of Business? (estimated) *
The Employer Is a: *
Injuries from Medical Malpractice: *
Type of Driver's License: *

Private Commercial
Which Type of Violation? *

Disregarding a Red Light Disregarding a Stop Sign DMV Letter About License DUI/DWI Failure to Appear in Court License Suspended/Revoked Minor in Possession of Alcohol No Child Safety Seat No Liability Insurance No Seat Belt Open Container of Alcohol Parking Ticket Racing Speeding Unpaid Traffic Tickets Warrant Issue for Arrest Other Violation
Do You Have a Court Date? *

Yes No
Type of Assets: *

Business Interests Cash Life Insurance Policies Pensions/Retirement Personal Possessions Property Stock/Bonds
What Is Your Role in this Matter? *
Relationship to the Victim: *
Were Criminal Charges Filed? *

Yes No Not Sure
What was the Cause of the Victim's Death? *
Type of Property: *
Total Amount of Payments that are Past Due: *
Total Amount of Loan? *
Have You Received a Notice of Default from the Lender? *

Yes No
Area of Real Estate: *
I Would Like a Lawyer to: *

Give me general advice to protect my interests Act as my agent in the transaction Assist me in the remaining stages of the transaction Bring a lawsuit against another party Defend against a lawsuit filed by another party Other
Legal Services Needed for Your Estate: *
Which Level of Tax Issue? *
Type of Tax Issue: *
How Likely Are You to Pay if Your Issue Could be Resolved? *
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How Will You Pay Legal Fees if You Hire a Lawyer? *
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Please provide any additional details of your legal issue below. *

First Name *
Last Name *

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Email *
Phone Number *
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