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English (US)
Law Firm Funding 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:
Corporation
Professional Corporation
Limited Liability Company
Partnership
Limited Liability Partnership
Sole Proprietorship
Other
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?
No
Yes (please explain briefly)
Does the firm have either duly executed retainer agreements or an OCA filed for each of its cases?
No
Yes
Does the firm represent any clients in which the agreed upon contingent fee is less than one-third of the recovery (after deducting disbursements)?
No
Yes
Does the firm currently maintain a line of credit or other borrowing?
No
Yes (Please enter lender and amount outstanding)
Amount of financing requested:
*
Min: $500,000 Max: $100,000,000.00
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?
No
Yes (Please specify amount of life insurance)
Are all partners/members of the law firm in good standing?
No
Yes
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); Lawsuit(s); Other liens
No
Yes
Judgment(s);
No
Yes (Please Expalin Below)
Tax liens / Open Tax Liability
No
Yes (Please Expalin Below)
Lawsuit(s)
No
Yes (Please Expalin Below)
Bankruptcy
No
Yes (Please Expalin Below)
Other liens
No
Yes (Please Expalin Below)
Signature of applicant
*
Credit Authorization Statement
Applicant name
*
Title
Home address (number; street; city or town; state; ZIP code)
*
Number; street; city; state; ZIP code
Mobile Phone
*
Date of birth
*
/
Month
/
Day
Year
Date
Social Security Number
*
Signature of applicant
*
Date
*
/
Month
/
Day
Year
Date
Document Requests
Please provide the documents requested below:
Ready to upload more documents?
Yes
Not at this time
Legal Underwriting Document Upload:
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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Financial Underwriting Documents
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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of
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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Closing Documents
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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Confidential Attorney Financial Statement
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.
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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, oy have you ever had: Judgment(s); Tax liens / Open Tax Liability; Lawsuit(s); Lawsuit(s); Other liens
No
Yes
Judgment(s);
No
Yes (Please Expalin Below)
Tax liens / Open Tax Liability
No
Yes (Please Expalin Below)
Lawsuit(s)
No
Yes (Please Expalin Below)
Bankruptcy
No
Yes (Please Expalin Below)
Other liens
No
Yes (Please Expalin Below)
Alimony/ Child Support/ Property Settlement Obligations
No
Yes (Please Expalin Below)
Signature
*
Date
*
/
Month
/
Day
Year
Date
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