Financing for law firms, clients, heirs, and estate and trust administrators

Please complete all parts of the form. Do not leave any sections blank.
Your Information
Your Full Name
Address 1
Address 2
City
State
Zip Code
E-Mail	* required
Date of Birth
Social Security Number
Home Phone
Work Phone
Mobile Phone

Attorney Information
Attorney's Full Name
Name of Law Firm
Address 1
Address 2
City
State
Zip Code
Phone Number
Fax Number
Is the attorney or law firm handling more than one accident case for you?
If yes,provide the name of the case or cases you would like us to Fund:

Accident/Case Information

Is any other attorney handling a Personal Injury case for you?

If yes, please explain:

Date of Accident or Injury

Name[s] of Defendant[s]

Describe Accident/Cause of injury

What injury did you receive from the accident?

Had you ever been treated for the same type of injury before your accident?

If yes, please explain:

If you were working at the time of the accident or injury, how much time did you miss from work because of the accident or injury?

year[s]

month[s]

week[s]

day[s]

Have you returned to work?

Additional Information
Have you receive funding or cash advance from another funding company on this or any other case?
If yes, please provide the following:
Amount of Advance
Name of Funding Company
Date Advance was Received
Are there any outstanding liens on the case? Example - Medical, Hospital, Workman's Compensation, Disability, Tax. Child Support etc.
If yes, please explain:
Are you now bankrupt or have you filed for bankruptcy?
If yes, please provide the following:
Date of Bankruptcy Filing
Location of Bankruptcy Filing
Were you discharged from bankruptcy?
If yes, date:
I understand that I am asking for funds to cover basic necessities. Amount of Funding Requested $
I need these funds for:
How did you hear about us?
Newspaper	Television
Magazine	Internet / Website
Radio	Other
In order to obtain information about your case, we need your authorization to release your case records and information to us. We cannot proceed without it. Dear Enter your ATTORNEY'S NAME here : I request and authorize that my attorney provide to LawStreetCapital whatever information, whether oral or in writing, that it needs in order to evaluate my funding request and that I specifically waive any privilege that I may have in this regard. I hereby request and authorize your firm to cooperate and release to LawStreetCapital any and all information and documents pertaining to my current case. I additionally ask that you share your candid opinion regarding this action with the above firm, in order to assist LawStreetCapital in evaluating the matter for funding purposes. I acknowledge that I understand the benefits/risks of non-recourse funding. I further acknowledge that I understand the effects of disclosing the contents of my file, including waiver of the attorney-client and work product privileges. Thank you in advance for your cooperation in this matter. Enter your FULL NAME here: Enter TODAY'S DATE here: By clicking here you indicate that you have read and agree to the Records Release Authorization. You must check this box to have your application processed. This gives us permission to contact your attorney and discuss your case with the attorney. By submitting this form I agree that all the information listed is accurate to the best of my knowledge.

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