Request for Legal Assistance
Business Name
*
Primary Contact Name
*
Contact Telephone Number
*
Contact Email Address
*
Names of additional owners of the business (if applicable)
Business Address
Type of Business
Number of Employees
Do you need assistance with insurance claims?
*
Yes
No
Do you need assistance with employment issues?
*
Yes
No
Do you need assistance with property issues?
*
Yes
No
Do you need assistance with banking, credit card, or debt issues?
*
Yes
No
Do you need assistance with contract issues?
*
Yes
No
Do you need assistance with other issues?
*
Yes
No
Please provide a brief description of the legal issues you would like assistance with.
*
Number of adults in your household
Number of children under age 18 in your household
Approximate gross household income
Income listed above is (select one):
Monthly
Annual
Is translation or an interpreter needed?
Yes
No
Have you worked with any of the following organizations? Please select all that apply.
Provide any additional information you want to include here.
Please provide any additional adverse party information here (if applicable).
Name/Contact Information of Intake Person (if applicable)
Intake Notes
*
Send me a copy of my responses
Submit
Powered by
Privacy Policy
Report Abuse