Please provide the following contact information:

Name
Title
Organization
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Country
Work Phone
FAX

Amount of Advance Requested?

Title/Style of Case:

Court Filed:

Date Filed:

-- mm/dd/yy

Description of Defendant:

Defendant's Attorney:

Insurance Company Indemnifying Defendant:

Nature of Action:

Damages Demanded $

Reasonable Expected Value of Settlement: $

Contingent Fee Percentage: $

Any Co-Counsel Involved to Share in Fees?

Yes
No

If YES, Name of Other Counsel and Percentage of Fees Due (% of Fees)

Have Settlement Talks Commenced?

Yes
No

If YES how soon is an Expected Settlement to be finalized?

30 Days 60 Days 90 Days 120 Days

If NO, what is the best estimate of an Expected Settlement?

90 Days 180 Days Other

Bank Name

City:

ABA Routing No:

Account Number:

Professional Reference (Legal Profession)

Name
Title
Organization
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Country
Work Phone
FAX
E-mail

Personal Reference (non-legal profession)

Name
Title
Organization
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Country
Work Phone
FAX
E-mail