Counsel Financial Application

Upload Case List

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Law firm name*

Contact name*

Law firm address*

Address

Street Address Line 2

City or Town State

Zip Code

Telephone*

Fax

E-mail*

example@example.com

Our law firm is a:

The firm has been in practice since

Please enter the date the Articles of Incorporation were filed for the firm or an estimate.

Number of partners

Number of associates and support staff

Description of practice areas

(i.e. Personal Injury, Mass Torts, Class Action, etc.)

Approximate number of cases pending

Total amount of money currently outstanding for case costs advanced by the law firm for its plaintiffs:

Approximate value of contingent fee inventory*

Does any other attorney or law firm have a financial interest in any of your cases?

NoYes (please explain briefly)

Does the firm have either duly executed retainer agreements or an OCA filed for each of its cases?

NoYes

Does the firm represent any clients in which the agreed upon contingent fee is less than one-third of the recovery (after deducting disbursements)?

NoYes

Does the firm currently maintain a line of credit or other borrowing?

NoYes (Please enter lender and amount outstanding)

Amount of financing requested:*

Min: $1,000,000 Max: $100,000,000

Use of funds:

Please give a brief description (i.e. working capital, case acquisition, payroll, etc.)

Do you or the law firm maintain any life insurance?

NoYes (Please specify amount of life insurance)

Are all partners/members of the law firm in good standing?

NoYes

Does the law firm or any partner or member currently have pending, or ever had any of the following filed by or against him/her/it: Judgment(s); Tax liens / Open Tax Liability; Lawsuit(s); Other liens

NoYes

Judgment(s)

NoYes (Please Explain Below)

Tax Liens / Open Tax Liability

NoYes (Please Explain Below)

Lawsuit(s)

NoYes (Please Explain Below)

Bankruptcy

NoYes (Please Explain Below)

Other Liens

NoYes (Please Explain Below)

Signature of applicant*

Applicant name*

Title

Home address (number; street; city or town; state; ZIP code)*

Number; street; city; state; ZIP code

Mobile Phone*

Date of birth*

Date

Social Security Number*

Signature of applicant*

Date*

Date

Ready to upload more documents?

YesNot at this time

Upload a copy of the firm’s organizational documents (e.g. certificate of incorporation, partnership agreement, etc.)

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Upload standard form of retainer agreement for the firm.

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Upload copies of any co-counsel agreements.

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Upload a copy of any other loan or financing agreement involving the firm.

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Upload copies of individual and firm tax returns for previous three years (for each partner).

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Upload profit and loss and balance sheet statements for current and previous three years.

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Upload a list of aged accounts payable of the firm at latest available date.

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Upload budget / projections for upcoming 24 months.

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Upload declarations page from malpractice insurance for the firm.

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Upload a copy of driver’s license (for each partner)

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Personal Financial Statement*

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*If you have a personal financial statement available, please upload it here in lieu of filling out the financial tables below.

Assets

	Amount
Cash, Savings, CDs
Marketable Securities (Schedule A)
Retirement Plans
Notes Receivable
Cash Value of Life Insurance (Schedule B)
Vehicles (year; make; model; amount)
Vehicles (year; make; model; amount)
Real Estate (Homestead)
Real Estate (other)
Other assets (description; amount)
Other assets (description; amount)
Total

Liabilities

	Amount
Notes Payable (Schedule D)
Notes Payable (Secured)
Notes Payable (Unsecured)
Credit Card Balances
Taxes Payable
Life Insurance Policy Loans
Mortgages (Homestead)
Mortgages (other)
Contingent Liabilities
Other Liabilities
Other Liabilities

Schedule A (Stocks & Bonds)

	NAME OF ISSUE AND TYPE OF SECURITY	WHERE TRADED	TOTAL VALUE	PLEDGED (Y/N)	REGISTERED IN NAME OF
1.
2.
3.

Schedule B (Cash Value of Life Insurance)

	COMPANY	POLICY #	FACE AMOUNT	CASH VALUE	POLICY LOANS	PLEDGED (Y/N)	BENEFICIARY
1.
2.
3.

Schedule C (Liabilities)

	LOCATION	PRESENT VALUE	MONTHLY INCOME	NAME ON TITLE	CREDITOR	OUTSTANDING BALANCE
1.
2.
3.

Schedule D (Real Estate)

	LENDER	ORIGINAL AMOUNT	PRESENT BALANCE	MATURITY	INTEREST RATE	COLLATERAL
1.
2.
3.

Schedule E (Contingent Liabilities)

	Other Companies You Have Equity Interest In	Current Indebtedness of Entity
1.
2.
3.

Do you currently, or have you ever had: Judgment(s); Tax liens / Open Tax Liability; Pending Lawsuit(s); Lawsuit(s); Other liens

NoYes

Judgment(s)

NoYes (Please Explain Below)

Tax Liens / Open Tax Liability

NoYes (Please Explain Below)

Lawsuit(s)

NoYes (Please Explain Below)

Bankruptcy

NoYes (Please Explain Below)

Other Liens

NoYes (Please Explain Below)

Alimony/ Child Support/ Property Settlement Obligations

NoYes (Please Explain Below)

Signature*

Date*

Date

Law Firm Funding Application

Credit Authorization Statement

Document Requests

Legal Underwriting Document Upload:

Financial Underwriting Documents

Closing Documents

Confidential Attorney Financial Statement