APPLICATION FOR REIMBURSEMENT CLIENT SECURITY FUND JD-GC-15 Rev. 1-15 P.B. §§ 2-68, 2-70 through 2-78 STATE OF CONNECTICUT JUDICIAL BRANCH www.jud.ct.gov ADA NOTICE The Judicial Branch of the State of Connecticut complies with the Americans with Disabilities Act (ADA). If you need a reasonable accommodation in accordance with the ADA, contact a court clerk or an ADA contact person listed at www.jud.ct.gov/ADA. Instructions 1. Review the information contained in the pamphlet The Client Security Fund Answers to Your Questions (Form JDP-GC-16) before completing this form. The pamphlet is available from the office of the Client Security Fund Committee or online at http://www.jud.ct.gov/Publications/GC016.pdf. 2. Provide the following information requested as completely as possible. If more space is needed, attach additional pages. 3. Submit copies of any documentation that you believe proves your loss, such as cancelled checks, receipts, letters, closing statements, etc. with your completed form. Do not submit original documents, as they will be made part of the file and will not be returned. 4. The form must be signed by you, and any other named claimant, under oath before a notary public or other authorized official. 5. Mail the completed application, and any supporting documents, to the address shown below. Applications that are incomplete may be returned without further review. To: Client Security Fund Committee, 2nd Floor, Suite One, 287 Main Street, East Hartford, CT 06118-1885 Your Name (First, Middle, Last) 1. Mr. Ms. Other Address (Number, street, town and zip code) E-mail Address Telephone Number 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? Please note that the fund may only reimburse losses that occurred in the course of an attorney-client relationship or in a fiduciary capacity arising out of an attorney-client relationship. 4. Describe the attorney's dishonest and/or fraudulent conduct (attach additional pages if necessary). Please note that in order for a claim to be reimbursable, it must involve conduct on the part of your attorney in the nature of a theft, embezzlement or the wrongful taking of money or property. In limited circumstances the committee may reimburse a loss based on an attorney's refusal to refund unearned fees paid in advance. Losses that are the result of negligence, malpractice, or investment services provided by the attorney are not covered by the client security fund: 5. State the amount of loss you claim should be reimbursed by the client security fund: 6. Did your loss involve: ("X" proper box or boxes) Money Securities 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): ("X" proper box) 8. How much did you pay this attorney? (Please include copies of any documents that are evidence of your payment or payments) 9. Did you have a written fee agreement with the attorney? (If yes, attach a copy of the agreement.) (Page 1 of 2) American LegalNet, Inc. www.FormsWorkFlow.com 10. 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 (for example, if you filed a civil action, provide the date the action was filed): 11. State the date when the loss of your money or property occurred (State how and when your loss was discovered): Please note that a loss presented more than four years after the loss was discovered or should have been discovered ordinarily is not reimbursable by the client security fund: 12. 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? ...... 13. This loss has been reported to: ("X" proper box or boxes) Please note that losses are not covered by the client security fund unless you have been awarded a judgment against the attorney, or the attorney that caused the loss has died, been adjudged incapable, been disbarred or suspended from the practice of law, has resigned from the practice of law, or been placed on probation or inactive status: 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 State's Attorney Police Statewide Grievance Committee Attach a copy of your complaint and describe what action was taken. 14. State the names and addresses of any witnesses or individuals having information concerning your claim: Name of Witness or Individual 1 Name of Witness or Individual 2 Address of Witness or Individual 1 (Number, street, town and zip code) Address of Witness or Individual 2 (Number, street, town and zip code) Telephone Number of Witness or Individual 1 Telephone Number of Witness or Individual 2 15. 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): 16. Name, address and telephone number of your present 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