Clients’ Security Fund of the D.C. Bar

Application for Reimbursement

Please complete and print the following application, have it notarized, attach all relevant documents, and mail the entire package to the Clients’ Security Fund of the District of Columbia Bar, 1250 H Street NW, Suite 600, Washington, DC 20005.

 (Please do not write in these spaces)
File No.
Date Filed:
Amount Sought
Amount Approved:
Investigating Trustee:
Date Concluded:
1.
Full Name of Applicant:
 Ms. Miss Mrs. Mr.
 
SSN or EID #
2.
Address of Applicant:
 
Home Phone:
 
Business Address:
 
Business Phone:
 
 
3.
Name, address, and phone number of attorney who caused your loss
 
Name:
 
Address:
 
Telephone:
 
 
4.
Please check all that apply. The attorney:
 
Died on
 
Was suspended on
 
Was disbarred on
 
Became a judgement debtor on in the amount of $
      Court entering judgement No.
 
Was adjudged guilty of a crime on
      Court entering judgement Docket No.
 
 
5.
State the amount of your loss:
  $  
 
 
6.
What was the attorney’s dishonest act that caused this loss?
 
 
 
7.
How much did you pay this attorney:
  $  
 
 
Please attach a copy of the fee agreement and copies of all receipts for the amount paid to the attorney
 
 
8.
State the date that you discovered the loss?
 
   
 
Has demand for reimbursement been made on the attorney?
 
yes
no
Date:
 
   
 
If so, how did the attorney respond to your demand?
 
 
 
9.
State the services that were performed and/or not performed by your attorney?
 
 
 
Please attach copies of any documents that will verify this statement. You may use additional sheets of paper if more space is needed.
 
 
10.
Was the dishonest conduct covered by insurance, indemnity, or bond?
  yes
no
unknown 		 
     
 
Name of Company
 
Address of Company:
 
 
11.
Were you, at the time of the loss, the spouse, close relative, partner, associate, employee, or emloyer of the attorney, or a business entity controlled by the attorney?
  yes
yes (please specify)
no
 
 
12.
What actions did you take in order to recover your loss?
  civil action
criminal action
fee arbitration
other (please specify)
 
 
Please attach a copy of any relevant documents
copies are attached
 
 
13.
Did you file an application with a client protection fund in another jurisdiction ?
  no yes  
   
 
If the answer is yes, please give the name of the other fund and the status of the other claim?
 
 
 
14.
If an attorney assisted you with this application, please state the name, address, and telephone number of the attorney.
  Name:
 
Address:
  Telephone Number:
     
Attorneys please note: The Rule of Court governing the Clients’ Security Fund provides: "No attorney shall be compensated for prosecuting a claim against the fund."
 
 
 
Date:
 
Signature of Applicant:
                                                   
 
 
 
Date:
 
Signature of Applicant:
                                                   
Verficiation and Assignment (Please do not write in these spaces)
File Name
File No.
File No.
Date Filed:
Amount Sought
Amount Approved:
Investigating Trustee:
Date Concluded:
City of } SS. State of } SS.
   
I, the undersigned applicant, hereby state that I have read the foregoing Application for Reimbursement submitted to the Clients’ Security Fund of the District of Columbia Bar and believe its contents to be true and accurate.
     I also agree that if the fund pays all or part of my claim for reimbursement, that payment will effectuate an assignment by me to the fund of any legal rights to reimbursement that I may have. Any recovery that the fund may obtain pursuant to this assignment will be applied to reimburse the fund for its payment to me and for any costs that the fund has incurred in obtaining that recovery. I am entitled to any additional amounts that the fund may recover.
     Finally, I agree to cooperate with the fund in any efforts that it may make to obtain a recovery based on the dishonest conduct that is the basis of this claim and to notify the fund if I file a claim with any other client protection fund arising out of the conduct that is the basis of this claim.
 
Date:
Signature of Applicant:
                                                   
   
Date:
Signature of Applicant:
                                                   
 
Subscribed and sworn to before me, the undersigned authority, on this day of , 20
   
Seal  
                                                     
  Signature of Notary Public
   
  My Commission expires

Please print the application, have it notarized, attach all relevant documents, and send the entire package to the
Clients’ Security Fund of the District of Columbia Bar, 1250 H Street NW, Suite 600, Washington, DC 20005.