Florida Bar Clients Security Fund Statement Of Claim

INSTRUCTIONS FOR COMPLETING THE CLIENTS222 SECURITY FUND CLAIM FORM 1. Please thoroughly review the information titled 223Clients222 Security Fund224 before filling out this form. 2. If you are filing a claim against more than one attorney you must fill out a separate form for each. 3. 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 or email for assistance. 4. Do not write in the margins of the claim form. If you need additional space, please use a separate sheet of paper. 5. This form will be electronically scanned. To help us get the best copies possible please: a. Please use black ink or type your information on the claim form. b. Do not make 223check size224 cutouts of checks. Use letter-size (8.5 x 11) paper. c. Do not staple your documents. Either use paper clips or leave them loose. d. 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. e. Please limit your attachments to 25 pages. 6. Please return the signed Statement of Claim form and accompanying documentation to: Clients222 Security Fund The Florida Bar 651 E. Jefferson Street Tallahassee, Florida 32399-2300 or scan and email to csf@floridabar.org If you have questions please call 850-561-5812 or 1-800-342-8060, ext. 5812. American LegalNet, Inc. www.FormsWorkFlow.com CONFIDENTIAL The Florida Bar Clients222 Security Fund Statement of Claim PLEASE TYPE OR PRINT USING BLACK INK 1. CLAIMANT: Mr. Ms. 2. ATTORNEY COMPLAINED AGAINST: Name: Name: Address: Address: City: State: Zip: City: State: Zip: Telephone No.: Email Address: 3. Amount of loss due to the misappropriation or wrongful taking by attorney: YOU MUST PROVIDE COPIES OF RECEIPTS, CANCELLED CHECKS (FRONT AND BACK) OR ANY OTHER EVIDENCE OF PAYMENT. 4. Describe in detail what you hired the attorney to do: (Attach a separate sheet if necessary.) 5. Describe in detail what the attorney did or did not do: (Attach a separate sheet if necessary.) 6. What was the fee arrangement you had with the attorney? (Attach a copy of any written fee agreement.) 7. Was any part of your case completed by another attorney? Yes No If so, give the name and address of the attorney: Attorney222s Name: Attorney222s Address: American LegalNet, Inc. www.FormsWorkFlow.com 8. Have you been reimbursed by anyone for any part of your claim? (Including insurance, bonding companies, the attorney, etc.) Yes No Amount: By Whom: 9. Have you received any offer of settlement by the attorney or other party? Yes No If yes, please explain: 10. Have you filed a grievance with The Florida Bar against the attorney? Yes No TFB File No. 11. Have you filed a civil suit against the attorney? Yes No Name of Court where filed: Case No.: Result: 12. Have you filed a criminal complaint against the attorney? Yes No Name of agency where filed: Complaint No.: 13. If the attorney is deceased, have you filed a claim against the attorney222s estate? Yes No Result: 14. Please tell us how you found out about the Clients222 Security Fund: 15. CLAIMANT ACKNOWLEDGEMENT: I UNDERSTAND THAT NO ONE HAS THE RIGHT OR ENTITLEMENT TO RECOVER MONEY FROM THE CLIENTS222 SECURITY FUND AS A THIRD-PARTY BENEFICIARY OR OTHERWISE. DECISIONS OF THE BOARD OF GOVERNORS OF THE FLORIDA BAR ARE FINAL AND NOT SUBJECT TO APPEAL. 16. ASSIGNMENT OF CLAIM: UPON PAYMENT BY THE CLIENTS222 SECURITY FUND TO THE CLAIMANT OF ALL OR ANY PORTION OF THIS CLAIM, THE CLAIMANT DOES HEREBY TRANSFER, ASSIGN AND SET OVER TO THE CLIENTS222 SECURITY FUND OF THE FLORIDA BAR ALL OF THE CLAIMANT222S 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 CLIENTS222 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 CLIENTS222 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. American LegalNet, Inc. www.FormsWorkFlow.com CLAIMANT AGREES TO COOPERATE IN THE INVESTIGATION OF THIS CLAIM AGAINST THE ATTORNEY IN QUESTION. AS A CONDITION PRECEDENT TO ANY PAYMENT FROM THE CLIENTS222 SECURITY FUND, CLAIMANT AGREES TO EXECUTE AND DELIVER TO THE CLIENTS222 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 223CLIENTS222 SECURITY FUND224. CLAIMANT: Signature ATTORNEY FOR CLAIMANT Claimant222s attorney, if any, must sign the above space which certifies that he/she will accept no fee for services Date in connection with this claim. (CSF Reg. E.2.) American LegalNet, Inc. www.FormsWorkFlow.com