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CLIENT
PROTECTION PROGRAM CLIENT PROTECTION PROGRAM CLAIM FORM Instructions: Answer every question in this application. If space is inadequate, attach additional pages. It is important that you submit all evidence that proves your loss, such as canceled checks, receipts, letters, closing statements, etc. Please Note: The ARDC does not accept claims by e-mail. PLEASE PRINT OR TYPE. 1. Your name: _____________________________________ Street address, Apt. #: _______________________________ City: ________________________ State: ____ Zip: _______ Home phone number: ______________________________ Cell phone number: _______________________________ Business phone number: ____________________________ 2. Name, address
and telephone number of the attorney whose conduct caused your loss: Street address: ______________________________________ City: _______________________ State: ____ Zip: _________ Phone number: ______________________________________ 3. Date you hired the attorney: __________________________ Date attorney/client relationship ended: ____________________ 4. What legal services did you ask this attorney to perform for you? __________________________________________________ __________________________________________________ __________________________________________________ 5. How much money did you pay this attorney? ______________ State the amount of your loss: ___________________________ 6. Was your agreement with this attorney in writing?
Yes___ No___ 7. Did any part of the loss consist of money given to the attorney in payment of fees? If yes, state the amount: ___________________ 8. Describe how and when your money or property came into the attorney’s possession: ___________________________________________________ ___________________________________________________ ___________________________________________________ 9. State the date when the loss of your money or property occurred: ___________________________________________________ 10. State the date when you discovered your loss, and how you discovered the loss: 11. Describe the attorney’s conduct and how it caused your loss: ___________________________________________________ ___________________________________________________ ___________________________________________________ 12. Provide the names and addresses of any other persons who have knowledge of the loss: ___________________________________________________ ___________________________________________________ 13. This loss has been reported to:
State’s Attorney ____ Police ____ Furnish a copy of your complaint and describe what action was taken: ___________________________________________________ 14. If you have not previously reported this loss, explain why: ___________________________________________________ ___________________________________________________ ___________________________________________________ 15. Can your loss be reimbursed from any other source, such as insurance, fidelity bonds or surety agreements? Yes ____ No ____ Don’t know ____ If yes, describe the source: ___________________________________________________ ___________________________________________________ 16. Describe what steps you have taken to recover the loss directly from the attorney, or any other source: ___________________________________________________ ___________________________________________________ ___________________________________________________ 17. If the loss caused you special hardship, explain how: ___________________________________________________ ___________________________________________________ ___________________________________________________ 18. State whether you have ever had a family or business relationship with the attorney and identify the relationship (e.g. spouse, child, parent grandparent, sibling, partner, associate or employee): ___________________________________________________ ___________________________________________________ ___________________________________________________ 19. State other facts that you believe are important to the Program’s consideration of your claim: ___________________________________________________ ___________________________________________________ ___________________________________________________ 20. Name of present attorney: ____________________________ Street address: _______________________________________ City: ___________________________ State: ____ Zip: _______ Phone number: ________________________ Commission rules do not permit attorneys who help clients process claims with the Program to charge legal fees for that service. When the Commission makes a decision on your claim, the facts relating to your loss become a public record Date: ________________ Signature of Claimant(s): ________________________________
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