Potential Client Information Sheet

MICHAEL P. MADDUX, P.A. CONFIDENTIAL CLIENT INFORMATION WORKSHEET

Thank you for completing this important form
PERSONAL INFORMATION:
Today's Date

MonthDayYear
Date
First Name
Middle Initial
Last Name
Address

Street Address

Street Address Line 2

CityState

Zip Code
Home Phone Number
Cell Phone Number
Work Phone Number
Date of Birth

MonthDayYear
Date
Social Security Number
Marital Status
E Mail Address
example@example.com
*Our office prefers to send you copies of letters, documents and other information by e-mail. Therefore, it is important to make sure this e-mail is regularly used by you.
Place of Birth (City and State)
Who can we thank for referring you to our Office?
Name of Spouse
Spouse's SSN
Spouse's Date of Birth

MonthDayYear
Date
Number of Children
Are you in this country legally?
Do you owe child support?
What money do you owe to the State of Florida?
EMPLOYMENT INFORMATION:
Employer
Employer's Address
Title
Rate of Pay
Did you lose time from work? If so, how much time? For What reason?
CONFIDENTIAL CLIENT INFORMATION WORKSHEET
Date of Incident

MonthDayYear
Date
Location of Incident
Name of Arresting Agency and/or Officer(s) Involved
Witnesses: Include addresses and telephone numbers, if available. If unknown, say so.
Description of Incident.
Injuries Immediately Following the Incident
Injuries as you sit in the office today
Rate your pain for each above answer on a 1 to 10 scale, 10 being the highest
Ambulance Company
Hospital
CONFIDENTIAL CLIENT INFORMATION WORKSHEET
Doctor - Include Address and Phone Number, if available
Doctor - Include Address and Phone Number, if available
Doctor - Include Address and Phone Number, if available
Have you received medical treatment for this type of injury prior to this Incident?

YesNo
If so, please explain

YesNoDid you report the incident to the Internal Affairs Bureau (IAB)?
If so, please explain
If yes, the date of your statement to the IAB?

MonthDayYear
Date
Have you ever been represented by an attorney for any reason?

YesNoIf so, please explain:
Have you ever been represented by an attorney for any reason?
Prior Litigation: Please list each and every lawsuit you have been a party to; state the nature of the suit, your role and outcome
Prior Litigation: Please list each and every lawsuit you have been a party to; state the nature of the suit, your role and the outcome:
Prior Consultations about this Case: Who are the other lawyers you have consulted about this case and why are you not utilizing their services?
CONFIDENTIAL CLIENT INFORMATION WORKSHEET
Prior Arrests: Please list each and every arrest, State or Federal, the agency involved in your arrest, the legal outcome and whether you made any claims against law enforcement as a result of the arrest
Goals in Retaining our Firm
Because you may be the recipient of a monetary settlement at the conclusion of your case, we need to know if you have any judgements, liens or other claims that could be levied against your settlement proceeds (ex. IRS lien, damages awarded from a contract dispute, unpaid restitution from a criminal case that has been reduced to a judgment). Please list them below
*We require a mandatory cost deposit of $2,500.00 before we accept any civil rights case for investigation and potential legal representation. This money is used to offset the expense of obtaining documents such as medical records, police reports, state attorney's office files, internal affairs reports, video or audio surveillance and other items necessary for us to evaluate your case.
CONFIDENTIAL CLIENT INFORMATION WORKSHEET
Should be Empty:

PERSONAL INFORMATION:

EMPLOYMENT INFORMATION:

CONFIDENTIAL CLIENT INFORMATION WORKSHEET

CONFIDENTIAL CLIENT INFORMATION WORKSHEET

CONFIDENTIAL CLIENT INFORMATION WORKSHEET