What type of case do you have:–None–Auto AccidentCivil LitigationClass ActionMedical MalpracticePersonal InjuryProduct LiabilityRailroad Work InjurySex AbuseTraumatic Brain InjuryWrongful DeathOther
How did you hear about us?–None–Attorney ReferralInternet searchSocial mediaOther
How much money are you requesting?:
What would the funds be used for?:
Please tell us a little bit about your current financial situation:
First Name
Last Name
Street
City
State/Province
Zip
Country
Your Email
Phone Number:
Your attorney’s first and last name:
Your attorney’s law firm name:
Your attorney’s phone number:
Your Attorney’s email address:
Your Attorney’s law firm address:
How do you prefer to be contacted?:–None–EmailPhoneText
Do you currently receive needs based benefit? If so, please list which ones.:
(Optional) We would like to know a little more about the demographics of our applicants. Please note that this information has no effect on our decision to provide funding
Ethnicity:–None–African American/BlackAsianNative Hawaiian or Other Pacific IslanderCaucasian/WhiteHispanic/LatinoHispanic/Latino (Black)Hispanic/Latino (White)Middle Eastern/North AfricanMultiracialNativePrefer Not to Say
Household Income:–None–< $25,000$25,000 to $50,000$50,000 to $100,000$100,000 to $200,000$200,000 +
