Apply for Funding

In what state is your case:

What type of case do you have:

Case Name:

Case Stage:

What was the date of the incident? (mm/dd/yyyy) (If applicable):

How much money are you requesting?:

What would the funds be used for?:

Expected Settlement Date (mm/dd/yyyy):

Please tell us a little bit about your current financial situation:

Your attorney’s first and last name:

Your attorney’s law firm name:

Your attorney’s phone number (10 digits, no spaces or hyphens):

Your Attorney’s email address:

Your Attorney’s law firm address:

How do you prefer to be contacted?:

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

Birthdate (mm/dd/yyyy):

Ethnicity:

Household Income: