Legal Funding Intake Form

1
DISCLAIMER: By proceeding with this claim submission form, you represent that you are the owner of a legal claim (a potential plaintiff in a lawsuit or arbitration), a party to pending litigation or arbitration seeking funding, or a lawyer representing a client seeking funding. You understand and agree that any information you submit through this form will be treated as confidential, and not disclosed to any third parties without your consent, but that submission of any information through this form does not create an agreement to fund, offer funding, or advise on funding with respect to your legal claim or defense. You understand and agree that no attorney-client relationship is formed as a result of your submitting information through this form, that any information submitted through this form may not be privileged, and that you should not submit any attorney-client privileged communications or information through this form. By clicking I AGREE below and proceeding to submit information through this form, you understand and agree to all of the foregoing.* This field is required.
I AGREEI DO NOT AGREE
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Plaintiff or Defendant* This field is required.Are you a potential or current plaintiff or defendant? (For attorneys: is your client a plaintiff or defendant?)
PlaintiffDefendant
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Claim Value* This field is required.Please provide your best estimate of the value of the legal claim, damages, or case for which you seek funding
Please input the number that corresponds to the dollar value. E.g., a $1 million claim should be input as 1000000
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Name* This field is required.
First Name
Last Name
5
Email* This field is required.
example@example.com
6
Phone Number* This field is required.
Area Code
Phone Number
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Are you represented by an attorney?* This field is required.If you are an attorney, please select Yes
YESNO
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If you are represented by an attorney, what is the attorney's name and firm?If you are the attorney representing the claimant, please provide your name and firm below
Attorney Name
Firm Name
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What is the nature of the dispute?* This field is required.Please select the option that best describes your claim
Please Select
Please Select
Breach of Contract
Personal Injury
Trade Secret (Theft/Misappropriation)
Patent Infringement
Trademark Infringement
Breach of Fiduciary Duty
Fraud
Whistleblower
Investor Rights
Defamation
False Advertising
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Please describe your claim, lawsuit, or arbitration.* This field is required.
Huge
Large
Normal
Small
Ok
Ok
11
How much funding are you seeking?* This field is required.Please provide your best estimate of how much funding you are seeking
Please input the number that corresponds to the dollar value. E.g., a $1 million request should be input as 1000000
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How do you plan to use the funding?* This field is required.
Huge
Large
Normal
Small
Ok
Ok
Should be Empty: