Your Information
*Full Name:
Date of Birth (month-day-year):
Address:
Apt:
City:
State:
Zip Code:
*E-Mail Address:
Social Security Number:
Home Phone:
Work Phone:
Cell Phone:
Your Attorney Information
Attorney's Full Name:
Name of Law Firm:
Phone Number:
Fax Number:
Address:
City:
Zip Code:
Law Firm Contact (paralegal/legal assistant):
Have you ever been injured in an incident or accident prior
If yes, provide details:
Case Information
Date of Incident(s), Accident, or Injury:
Name(s) of Defendant(s):
Describe Incident(s) / Accident / Cause of Injury:
Describe the nature of your injuries:
Describe the treatments you have received for your injuries:
If you were working at the time of the incident, accident or injury, how much time did you miss from work because of the incident, accident, or injury?
Are you still out of work?
Is the attorney or law firm handling more than
If yes, please provide a description of the additional case(s):
Did you receive an advance from another funding company on this case or any other case?
If Yes (Amount, Name of Funding Company, When Funded):
Are there any outstanding liens against you and/or the case? (medical, hospital, workman's comp, disability, IRS, etc.):
Have you now or ever filed for bankruptcy?
If yes (When and Where):
Was the bankruptcy discharged? If so, when?
Funding Information
Amount of Funding Requested:
I need these funds for:
Referral
How did you hear about us?
By submitting this form, I agree that all the information listed is accurate and correct. In order to obtain information about your case, we need your authorization to release your case records and information to us. We cannot proceed without it. Enter your ATTORNEY’S NAME here:
I request and authorize my attorney to provide LawCash with whatever information (whether oral or in writing) needed to evaluate my funding request. I specifically waive any privilege that I may have regarding such information.
I hereby request and authorize your firm to cooperate with and release to LawCash any and all information and documents pertaining to my case. Please share your candid opinion regarding this action with LawCash, so that LawCash can evaluate my funding request.
I acknowledge that I understand the benefits and risks of non-recourse funding. I further acknowledge that I understand the effects of disclosing the contents of my file, including waiver of the attorney-client and work product privileges.
Name:
Date:
By submitting this form I agree that all the information listed is accurate to the best of my knowledge.