APPLICATION FOR REIMBURSEMENT CLIENT SECURITY FUND
JD-GC-15 Rev. 5-06 P.B. §§ 2-68, 2-75
INSTRUCTIONS Answer every question on this application. Provide the information requested as completely as possible. If more space is needed, attach additional pages. It is important that you submit copies of any documentation that you believe proves your loss, such as cancelled checks, receipts, letters, closing statements, etc. The form must be signed by you, and any other named claimant, under oath before a notary public or other authorized official. Mail the completed application, and any supporting documents, to the address shown below.
TO: CLIENT SECURITY FUND COMMITTEE, 2nd FLOOR, SUITE ONE, 287 MAIN STREET, EAST HARTFORD, CT 06118-1885
1. Your name and address:
ADDRESS (No , street, town and zip code) HOME TELEPHONE
2. Name, address and telephone number of the attorney whom you claim dishonestly and/or fraudulently has taken your money or property:
3. What legal services did you ask this attorney to perform for you?
4. How much did you pay this attorney?
5. Was your agreement with the attorney concerning legal fees in writing? 6. Did your loss involve:
(If yes, attach a copy of the agreement.)
OTHER PROPERTY (Specify below)
7. Can your loss be reimbursed from any other source, such as insurance, fidelity bonds or surety agreements?
NO DON'T KNOW YES (If yes, describe this source below)
8. Describe what steps you have taken to recover the loss directly from the attorney, or any other source. Provide the date or dates when you took such steps (i.e., date a civil action was filed):
9. State the amount of loss you claim as reimbursable by the Client Security Fund:
(Page 1 of 2)
10. State the date when the loss of your money or property occurred: 11. State the date when you discovered your loss, and how you discovered your loss:
12. Describe the attorney's dishonest and/or fraudulent conduct (attach additional pages if necessary):
13. This loss has been reported to: STATE'S ATTORNEY POLICE Attach a copy of your complaint and describe what action was taken.
STATEWIDE GRIEVANCE COMMITTEE
14. State the names and addresses of any witnesses or individuals having information concerning your claim:
15. Answer the following questions to the best of your knowledge ("X" proper box) a. Has the attorney died?........................................................ b. Has the attorney been adjudged incapable?....................... c. Has the attorney been disbarred or suspended from the practice of law?............................................................. d. Has the attorney resigned from the practice of law?........... e. Has the attorney been placed on probation or inactive status by a Connecticut court?............................................ f. Have you been awarded a judgment against the attorney? 16. Name, address and telephone number of your present attorney:
NO NO NO NO NO NO YES, GIVE DATE: YES, GIVE DATE: YES, GIVE DATE: YES, GIVE DATE: YES, GIVE DATE: YES, GIVE DATE: UNKNOWN UNKNOWN UNKNOWN UNKNOWN UNKNOWN UNKNOWN
17. Are you related to the attorney you claim caused your loss, or are you an associate, partner, or employee of the attorney? No Yes (If yes, state your relationship with the attorney): NOTICE
The Practice Book rules governing claims filed with the Client Security Fund Committee do not permit attorneys who help clients process claims with the Fund to charge legal fees for that service, except with the permission of the Client Security Fund Committee. If it is determined that you should be reimbursed by the client security fund, you will be required to sign a document transferring your claim against the attorney to the Client Security Fund Committee, to the extent of the award made to you. By signing below, you agree to cooperate in the investigation of your claim and in the investigation of any related disciplinary or criminal proceedings, and you agree to cooperate with the Client Security Fund Committee in any action undertaken to recover amounts paid to you from the client security fund.
I, the undersigned, under oath say: I am the claimant in the above matter; I have read the foregoing and know the contents thereof; and I certify that the same is true of my own knowledge, except as to the matters and things which are therein stated upon my information and belief, and that as to those matters and things, I believe them to be true.
SIGNED (Claimant) DATE SIGNED DATE AT (Town) SIGNED (Commissioner of Superior Court, Notary Public)
Subscribed and sworn to before me on:
JD-GC-15 Rev. 5-06 (Back/Page 2)
(Page 2 of 2)