Intake Form

Please Fill The Form Below

Starting from 199$

Name

Email Address

Phone Number

Address

Occupation

Employment Status

Employed Retired Other

Name of Business, Person or Company with whom you have a dispute:

Summary of your dispute/issue:

Amount of total contract for goods or services:

Date contract was entered:

If you have complained to the Business, Person or Company, please summarize their response.

Has a lawsuit been filed?

Yes No

If a lawsuit has been filed list the names of the parties, the Court where filed, case number, opposing counsel’s name and contact information, and the amount requested.

If a lawsuit was filed, were the parties served?

Yes No

Have any settlement offers been made? If so, please summarize.

If any legal proceedings have been filed, please upload the following Supporting Documents or email to [email protected]. • Lawsuit or other court paperwork, including but not limited to garnishments. • Last account statement received • Any recent correspondence • Copy of Contract for goods or services and other paperwork received. • Repair orders or receipts • Pictures

State desired result, i.e. receive refund or reimbursement, receive property, settle amount, cease and desist or other relief:

Please tell us about any circumstances that have occurred that may be relevant.

Please tell us about any defenses you have to the payment on the contract, if applicable, i.e. improper service, mistaken identity, identity theft, statute of limitations, payment, amount disputed, lack of authority for plaintiff to sue, bankruptcy, unlicensed debt collector, or other excuse to contract enforcement or payment.

How did you hear about the us?

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