General Contact Information:

Your Name:

Accused Person's Name (if different from above):

Whom should we contact:

You     Accused Person

Please supply the following information for the person we should contact regarding this claim:

Street Address:

City:

State:

Zip:

E-mail Address:

Best time to contact you:

Select... 8am-12noon 12noon-4pm 4pm-8pm After 8pm

Home Number:

eg. 555-555-5555

Work Number:

eg. 555-555-5555

Mobile Number:

eg. 555-555-5555

Fax Number:

eg. 555-555-5555

Accused Information:

Date of Birth:

eg. 6/15/2003

Is he or she a U.S. citizen:

Select... Yes No

Is he or she in custody:

Select... Yes No

Amount of bail:

Name of jail:

Booking number:

Is he or she on probation:

Select... Yes No

Discuss prior arrests or charges:

Discuss the charges or accusations of this case:

Did an arrest occur:

Select... Yes No

Arrest date:

eg. 6/15/2003

Case number:

Name of court:

Next court date:

eg. 6/15/2003

Where did the incident occur:

Provide a detailed accounting of the incident including any witnesses to the incident:

Legal Issues:

Have you contacted any other lawyer about your case?

Select... Yes No N/A

If Yes, did the lawyer agree to represent you?

Select... Yes No N/A

Are you still being represented by the lawyer?

Select... Yes No N/A

Additional Information:

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Referred by a Friend
Other:

Are there any other questions you wish to have answered?