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If you are an attorney and searching for financing, please begin by filling out the following information below. This information is used to determine if you qualify for a litigation financing. You can fax this document back along with any supporting documents to 1-888-536-0188 or email to info(@)lawleaf.com.

*For a better view of this document please click on the PDF icon at the top right of the page and print.

Amount Requested: ___________________

LAW FIRM INFORMATION
Law Firm: ______________________________________________________________
Office Address: _____________________________________________________

_____________________________________________________
Office Phone: _____________________ Fax Number: ________________________
Business Structure (i.e. corporation, partnership, etc…): _______________________
Organization ID# with Secretary of State*: ____________________________________
*Required, except for the following states: AL, AR, MA, NC, NH, NY, OK, SC, VT, WV

TAX ID: __________________________ State of Incorporation: _________________
Year Established: ___________________ Number of Partners: ___________________
Are all Partners/Members of the firm in good standing? Yes _______; No ________
If not, explain: ________________________________________________
What is the Equity Ownership % Breakdown of the Firm Between the Partners?
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________

ATTORNEY INFORMATION (for each partner)
Attorney Name: __________________________________________________________
Home Address: _____________________________________________________

_____________________________________________________
Date of Birth: ____________________ Social Security Number: _________________
Home Phone: ____________________ Mobile Phone: _______________________
E-Mail: ________________________ Website: ____________________________
Driver’s License: State: _________ Number: ____________________________
Attorney License: State: _________ Number: ____________________________
Admitted to Practice: Year: _________ States: ______________________________

ADDITIONAL INFORMATION

Have you or the firm ever filed Bankruptcy? Yes _______; No _________
If yes, Date of Bankruptcy filing ___________
Date of Bankruptcy discharge _____________
Does the firm have any outstanding debt/lines of credit? Yes _______; No __________
If yes, has a UCC been filed? Yes _______; No __________
If yes, please specific: Source ________________ Amount $_________________
Does the firm have any outstanding cash advances? Yes _______; No __________
If yes, please specific: Source ________________ Amount $_________________
Have you ever taken an advance against your contingency fees before? Yes____; No_____
If yes, from which firm? ________________________________
Any pending claims / existing judgments against the firm? Yes _______; No __________
If yes, please specific: _________________________________________________
Are there any lawsuits currently against you or your firm? Yes ________; No __________
If yes, caption of case: _________________________________________________
Venue of case: _______________________________________________________
Docket/Index # of case: ________________________________________________
Have you or the firm ever had disciplinary actions filed against you? Yes _____; No _____
If yes, when filed? ____________________________________________________
What was the result? __________________________________________________
Does the firm maintain malpractice insurance? Yes _______; No __________
Insurance Co. __________________________________________
Insurance limits $___________ Policy Number ____________

ATTORNEY CONSENT FORM:
I hereby authorize and consent to have LawLeaf, and/or its agents, representatives, employees, or funding partners perform any and all necessary searches to investigate and evaluate this application for an Attorney Advance, including, but not limited to, background checks, credit checks, and any type of search relating to my financial status or that of my firm. I further acknowledge that LawLeaf and/or its funding partners will use this information to process this application and will materially rely on all of the information contained in this application to determine advance eligibility. I further represent that, on behalf of the law firm and myself, I am authorized to consent to this investigation and enter into an Attorney Advance Agreement with LawLeaf and/or its funding partners.

Signed: __________________________ Date: ___________________