TLS - Backpage Remission Program Eligibility Intake

Backpage Remission Program

Client Eligibility Intake Form. Claim Filing Deadline: February 2, 2026
Eligibility Screening

*Fields marked with * are required
1. Were you advertised on Backpage.com or CityXGuide.com between 1/1/2004 - June 19, 2020? (If No, you are not eligible for this program. Thank you for your interest.)*

YesNoUnsure
2. If yes, which platform(s)?*

Backpage.com (January 1, 2004 – April 6, 2018)CityXGuide.com (April 8, 2018 – June 19, 2020)Both
3. Were you:*

Self-advertisedAdvertised by someone else (trafficker, pimp, or other person)BothUnsure
4. Approximate dates you were advertised:*
5. Did you incur any of the following losses as a result of being advertised on Backpage or CityXGuide? (Check all that apply - If None of the above, you may not be eligible for compensation. Eligible losses must be documented.)*

Medical expensesMental health or behavioral health treatment (therapy, counseling, substance use treatment)Lost wagesOther out-of-pocket expenses related to traffickingNone of the above
6. Do you have any documentation to support your losses? (e.g., medical records, receipts, therapy records, screenshots of ads, text messages, emails)*

YesNo, but I can obtain documentationNo, and I am unsure how to obtain documentation
Contact Information

*Fields marked with * are required
Full Legal Name:*

First NameMiddle NameLast Name
Other Names Used:
(aliases, maiden name, etc.)
Date of Birth:*

MonthDayYear
Date
Phone Number:*
Please enter a valid phone number.
Email Address:*
example@example.com
Mailing Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Preferred Contact Method:*

PhoneEmailText
Prior Compensation

*Fields marked with * are required
7. Have you received any compensation related to your trafficking from other sources? (e.g., civil lawsuit, state victim compensation fund, restitution)*

YesNo
If yes, please describe:
Additional Information

*Fields marked with * are required
8. Stay connected with The Law Shed.*

Yes, I would like to receive updates, newsletters, and information about other settlements and legal services from The Law Shed. I understand this is optional and not required to participate in the Backpage Remission Program.No
9. Is there anything else you would like us to know?
Attorney Advertising Disclaimer
1. This information is provided by T.K. Sheth Law LLC d/b/a The Law Shed, an independent law firm assisting participants in the Backpage Remission Program.
2. Petitioners are not required to retain legal counsel. Free assistance is available from the Remission Administrator at www.backpageremission.com and through the Backpage Survivor Remission Network at www.backpageremissionnetwork.org.
3. Submitting a petition does not guarantee payment. Eligibility and payment amount are determined solely by the DOJ and Remission Administrator.
4. All information provided will be used solely for petition processing and is protected under applicable confidentiality laws and rules of professional responsibility.
5. No attorney-client relationship is formed unless and until a written engagement agreement is executed by both parties.
6. This material constitutes attorney advertising. Prior results do not guarantee future outcomes.
7. Attorney Tanvi K. Sheth is licensed in Illinois. The Law Shed's representation is limited to administrative petition filing and does not include legal advice outside Illinois unless permitted under applicable rules.
8. Fee Disclosure: Representation is on a 30% contingency fee basis. There are no upfront costs or expenses charged to the client.
Consent and Authorization: By completing and submitting this intake form, I acknowledge and agree that: I am providing my information to T.K. Sheth Law LLC d/b/a The Law Shed for the purpose of pursuing a claim in the Backpage Remission Program. I authorize The Law Shed to prepare, sign, and submit my claim form to the Claims Administrator on my behalf, and to communicate with the Claims Administrator regarding my claim. The information I have provided is true, accurate, and complete to the best of my knowledge, information, and belief. I understand that The Law Shed, the Settlement Administrator, or Class Counsel may request additional information or documentation to support my claim, and I agree to provide it if requested. I consent to be contacted by The Law Shed electronically, including by email and/or mobile text message (message & data rates may apply), regarding this claim and related representation.*

YesNo
⚖️ Engagement Reminder
Important Notice:
Completing this intake form is only the first step. In order to become a client of T.K. Sheth Law LLC d/b/a The Law Shed, you must also review and sign a separate Engagement Agreement.

No attorney-client relationship is formed until both of the following occur:

You complete this intake form; and
The Engagement Agreement is signed by you and accepted by the attorney.
The attorney will not accept representation without a completed intake form on file.
Office Use Only
Date

MonthDayYear
Date
Reviewed By:
Eligibility Determination:

EligibleNot EligibleNeeds Follow-Up
Notes:
Contact Us:

Office Line: 312-219-2447
Attorney Tanvi Kaushal Sheth Cell: 847-529-8279
Email: hi@thelawshed.com
Should be Empty:

Backpage Remission Program

Eligibility Screening

Contact Information

Prior Compensation

Additional Information

Office Use Only