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Statement Of Claim (Clients Security Fund) - Florida
| Statement Of Claim (Clients Security Fund) Form. This is a Florida form and can be used in Miscellaneous Florida Bar Statewide . |
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INSTRUCTIONS FOR COMPLETING THE CLIENTS' SECURITY FUND CLAIM FORM 1. Please thoroughly review the information titled "Clients' Security Fund" before filling out this form. If you are filing a claim against more than one attorney, you must fill out a separate form for each. It is very important that you answer all questions on the form and provide facts and documentation (copies, not originals) in support of your claim. If you do not understand any portion of the form, please call for assistance. Do not write in the margins of the claim form. If you need additional space, please use a separate sheet of paper. Photocopies of this form will be made. To assist us in obtaining the best copies possible, please: a. b. c. d. e. Please use black ink or type your information on the claim form. Do not make "check size" cutouts of checks. Use letter-size (8.5 x 11) not legal-size (8.5 x 14) paper. Do not staple your documents. Either use paper clips or leave them loose. Do not use highlighters or tabs to emphasize parts of your claim. If you would like to direct attention to certain information, please do so in a different manner such as underlining. Please limit your attachments to 25 pages. pages will be returned. Attachments over 25 2. 3. 4. 5. f. 6. Please return the signed original Statement of Claim form and accompanying documentation, to: Clients' Security Fund The Florida Bar 651 E. Jefferson Street Tallahassee, Florida 32399-2300 If you have any questions, please call 850-561-5812 or 1-800-342-8060, ext. 5812. American LegalNet, Inc. www.FormsWorkFlow.com CONFIDENTIAL The Florida Bar Clients' Security Fund Statement of Claim PLEASE TYPE OR PRINT USING BLUE OR BLACK INK 1. CLAIMANT: Name: Address: City: Home Phone No.: Work Phone No.: 3. Mr. Ms. 2. ATTORNEY COMPLAINED AGAINST: Name: Address: City:: State: Zip: Home Phone No.: Work Phone No.: State: Zip LOSS CLAIMED: Amount of loss due to the misappropriation, embezzlement or wrongful taking by attorney. $ STATEMENT OF FACTS AND SUPPORTING DOCUMENTS: Describe in detail what you hired the attorney to do. (Attach a separate sheet if necessary.) 4. (A) (B) Describe in detail what the attorney did or did not do. (Attach a separate sheet if necessary.) (C) Date money was given to attorney: (You must provide copies of receipts, cancelled checks, [front and back] or any other evidence of payment.) (D) Date loss discovered: (E) Did you request repayment from the attorney: Yes No If so, when: 5. (A) FEE ARRANGEMENT WITH ATTORNEY: State the fee arrangement you had with your attorney: (Attach a copy of any written fee agreement.) (B) Was any part of your case completed by another attorney? If so, give the name and address of the attorney: Attorney's Name: Attorney's Address: Yes No American LegalNet, Inc. www.FormsWorkFlow.com 6. (A) REIMBURSEMENT: Have you been reimbursed by anyone for any part of your claim? (Including insurance, bonding companies, the attorney etc.): Yes No Amount: $ By Whom: Have you received any offer of settlement by the attorney or other party? If yes, please explain. Yes No (B) 7. Have you filed a civil suit against the attorney? Name of Court where filed: Result: Yes No Case No.: 8. Have you filed a criminal complaint against the attorney? Name of agency where filed: Complaint No.: Yes No 9. CLAIMANT ACKNOWLEDGEMENT: I UNDERSTAND THAT NO ONE HAS THE RIGHT OR ENTITLEMENT TO RECOVER MONEY FROM THE CLIENTS' SECURITY FUND. DECISIONS OF THE BOARD OF GOVERNORS OF THE FLORIDA BAR ARE FINAL AND NOT SUBJECT TO APPEAL. ASSIGNMENT OF CLAIM: UPON PAYMENT BY THE CLIENTS' SECURITY FUND TO THE CLAIMANT OF ALL OR ANY PORTION OF THIS CLAIM, THE CLAIMANT DOES HEREBY TRANSFER, ASSIGN AND SET OVER TO THE CLIENTS' SECURITY FUND OF THE FLORIDA BAR ALL OF THE CLAIMANT'S CLAIMS, DEMANDS, CAUSES OF ACTION, ACTIONS AND SUITS ARISING OUT OF THE ABOVE-DESCRIBED ACTS FOR WHICH THIS CLAIM IS MADE, TO THE EXTENT OF PAYMENT BY THE FUND. THE UNDERSIGNED AUTHORIZES THE CLIENTS' SECURITY FUND OF THE FLORIDA BAR TO PROSECUTE ALL SUCH CLAIMS, DEMANDS, CAUSES OF ACTION, ACTIONS AND SUITS, EITHER IN THE NAME OF THE UNDERSIGNED OR IN THE NAME OF THE CLIENTS' SECURITY FUND OF THE FLORIDA BAR, OR IN THE NAMES OF BOTH, AS THE FLORIDA BAR, IN ITS SOLE JUDGMENT, SHALL DEEM ADVISABLE. THE CLAIMANT AGREES TO COOPERATE WITH THE FUND IN ANY EFFORTS BY THE FLORIDA BAR IN ENFORCING ANY CLAIM, DEMAND, CAUSE OF ACTION, ACTIONS OR SUITS, AND AGREES THAT ALL CIVIL ACTIONS TO BE TAKEN HEREUNDER SHALL BE UNDER THE FULL CONTROL OF THE FLORIDA BAR AND THE FLORIDA BAR MAY, AS IT DEEMS ADVISABLE, PROSECUTE OR FAIL TO PROSECUTE OR ABANDON ANY SUCH CLAIM, DEMANDS, CAUSE OF ACTION, ACTIONS OR SUIT WITHOUT THE NECESSITY OF ANY CONSENT OR APPROVAL OF THE UNDERSIGNED. THE CLAIMANT AGREES TO NOTIFY THE FLORIDA BAR IN THE EVENT ANY PAYMENT FROM ANY OTHER SOURCE IS RECEIVED. CLAIMANT AGREES TO COOPERATE IN THE INVESTIGATION OF THIS CLAIM AGAINST THE ATTORNEY IN QUESTION. AS A CONDITION PRECEDENT TO ANY PAYMENT FROM THE CLIENTS' SECURITY FUND, CLAIMANT AGREES TO EXECUTE AND DELIVER TO THE CLIENTS' SECURITY FUND OF THE FLORIDA BAR SUCH DOCUMENT OR DOCUMENTS AS MAY BE REQUIRED. UNDER PENALTY OF PERJURY, I DECLARE THE FOREGOING FACTS ARE TRUE, CORRECT AND COMPLETE. I FURTHER CERTIFY THAT I HAVE READ AND UNDERSTAND THE INFORMATION CONTAINED IN THE PAMPHLET "CLIENTS' SECURITY FUND." 10. CLAIMANT: ATTORNEY FOR CLAIMAINT Claimant's attorney, if any, shall sign the above space which certifies that he/she will accept no fee for services in connection with this claim. (CSF Reg. E.2.) Signature Date MAIL TO: Client's Security Fund, The Florida Bar, 651 E. Jefferson Street, Tallahassee, Florida 32399-2300. American LegalNet, Inc. www.FormsWorkFlow.com
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