MINNESOTA CLIENT SECURITY BOARD
CLAIM FORM

Staff Office
1500 Landmark Towers
345 St. Peter Street
St. Paul, Minnesota 55102-1218
(651) 296-3952
Toll-free 1-800-657-3601
Fax (651) 297-5801
TTY users call MN Relay service
Toll-free at1-800-627-3529

I hereby apply to the Minnesota Client Security Board for payment of a loss I claim I suffered because of my lawyer's dishonesty. I understand that payment by the Board is discretionary and not a matter of right.

1. My name, address and telephone number are as follows:

Name:
Address:
Phone:

2. The name, address and telephone number of the lawyer whose dishonest act caused me the loss are:

Name:
Address:
Phone:

3. When the loss occur:

a. When did you hire the lawyer to represent you?

b. When did the loss occur?

c. When did your attorney-client relationship with the lawyer end?

4. How the loss occurred:

a. Describe in detail what the lawyer did that was dishonest and how this caused your loss (if space is insufficient, you may attach more papers):

b. When did you learn of the attorney's dishonest act?

5. The amount of loss:

a. How much money or property did the attorney's dishonest act cause you to lose?

b. How did you calculate the amount of this loss?

c. When and how did your money come into the lawyer's possession?

6. Attach copies of all relevant documents, including correspondence, bank statements,
receipts, copies of canceled checks and names and addresses of witnesses (if any).

7. Other actions you have taken to recover your loss:

a. Have you sued the lawyer?

b. Have you made any other claim against the lawyer or the lawyer's assets (such as insurance claims, arbitration claims, etc.)?

c. Have you contacted the appropriate criminal authorities about possible prosecution?

If the answer to any of these is yes, please attach copies of your claim or pleadings. If the answer is no, please explain why you have not taken such action.

8. Has your loss caused you any special hardship? If so, please describe.

9. I swear that the above information is accurate and complete.

                                                               

[Signature of Claimant]

SUBROGATION AGREEMENT

If the Client Security Board pays me any amount for my loss, I agree that the Board shall be subrogated, in the amount of the payment to me, to all my rights against the lawyer named in this claim, the lawyer's assets, the lawyer's estate, the lawyer's law firm or partner(s) or any other person(s) or entity(ies) against which subrogation rights may be enforced. I authorize the Board to take any action on the subrogated claim. I understand that I shall be notified if the Board takes action. I agree to cooperate with reasonable requests from the Board for assistance in pursuing any action on the subrogated claim including requests for information and/or documents and/or to testify. I also recognize that I may join in the action to press a claim for my loss in excess of the amount paid to me by the fund, but the fund shall have first priority to any recovery in the suit.

                                                               

[Signature of Claimant]

SIGNED AND SWORN to before me on

                                                   , 20        .

              [month]               [day]

by:                                                              

                                                                   

[Notary Public Signature]