Fillable Application for Reimbursement (Oregon State Bar)

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Application for Reimbursement (Oregon State Bar)

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The Application for Reimbursement (Oregon State Bar) form is 4 pages long and contains:

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  • 9 check-boxes
  • 64 other fields

Country of origin: US
File type: PDF

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1. Information about the client(s) making the claim:
a. Full Name: ____________________________________________________________________________________________
b. Street Address: ________________________________________________________________________________________
c. City, State, Zip: ________________________________________________________________________________________
d. Phone: (Home) _______________________________________ (Cell) ____________________________________________
(Work) ________________________________________ (Other) __________________________________________
e. Email: _______________________________________________________________________________________________
2. Information about the lawyer whose conduct caused your claim (also check box 10A on page 3):
a. Lawyer's Name ________________________________________________________________________________________
b. Firm Name ____________________________________________________________________________________________
c. Street Address: ________________________________________________________________________________________
d. City, State, Zip: ________________________________________________________________________________________
d. Phone: ________________________________________________________________________________________________
e. Email: _______________________________________________________________________________________________
3. Information about the representation:
a. When did you hire the lawyer? __________________________________________________________________________
b. What did you hire the lawyer to do? _____________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
c. What was your agreement for payment of fees to the lawyer? (attach a copy of any written fee agreement)
______________________________________________________________________________________________________
d. Did anyone else pay the lawyer to represent you? __________________________________________________________
e. If yes, explain the circumstances (and complete item 10B on page 3):
______________________________________________________________________________________________________
______________________________________________________________________________________________________
f. How much was actually paid to the lawyer? (please attach proof of payment, if any) ___________________________
g. What services did the lawyer perform? ___________________________________________________________________
______________________________________________________________________________________________________
Client Security Fund
Application for Reimbursement
Return completed form to:
Oregon State Bar
Client Security Fund
PO Box 231935
Tigard, OR 97281-1935
6/18 • Page 1
Payments from the Client Security Fund are entirely within the discretion of the Oregon State Bar.
Submission of this claim does not guarantee payment.
The Oregon State Bar is not responsible for the acts of individual lawyers.
Please note that this form and all documents received in connection with your claim are public records.
Please attach additional sheets if necessary to give a full explanation.
Print for Signature
h. Was there any other relationship (personal, family, business or other) between you and the lawyer?
______________________________________________________________________________________________________
4. Information about your loss:
a. When did your loss occur? _____________________________________________________________________________
b. When did you discover the loss? ________________________________________________________________________
______________________________________________________________________________________________________
c. Please describe what the lawyer did that caused your loss __________________________________________________
______________________________________________________________________________________________________
d. Total amount of your loss _______________________________________________________________________________
e. How did you calculate your loss? _________________________________________________________________________
f. Amount you are requesting to be reimbursed _____________________________________________________________
5. Information about your efforts to recover your loss:
a. Have you been reimbursed for any part of your loss? If yes, please explain: ____________________________________
______________________________________________________________________________________________________
b. Do you have any insurance, indemnity or a bond that might cover your loss? If yes, please explain: _______________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
c. Have you made demand on the lawyer to repay your loss? When? Please attach a copy of any written demand.
______________________________________________________________________________________________________
d. Has the lawyer admitted that he or she owes you money or has he or she agreed to repay you? If yes, please
explain: ______________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
e. Have you sued the lawyer or made any other claim? If yes, please provide the name of the court and a copy
of the complaint. ______________________________________________________________________________________
f. Have you obtained a judgment? If yes, please provide a copy ________________________________________________
g. Have you made attempts to locate assets or recover on a judgment? If yes, please explain what you found: _______
______________________________________________________________________________________________________
______________________________________________________________________________________________________
6. Information about where you have reported your loss:
p District attorney
p Police
p Oregon State Bar Professional Liability Fund
p Client Security Fund Claim in Another State — If yes, list state(s): ___________________________________________
If yes to any of the above, please provide copies of your complaint and any decisions, if available.
p Oregon State Bar Client Assistance Office or Disciplinary Counsel
7. Did you hire another lawyer to complete any of the work? If yes, please provide the name and telephone
number of the new lawyer: _______________________________________________________________________________
________________________________________________________________________________________________________
6/18 • Page 2
8. Please give the name and the telephone number of any other person who may have information
about this claim: ______________________________________________________________________________________
________________________________________________________________________________________________________
9. Agreement and Understanding
The claimant agrees that, in exchange for any award from the Oregon State Bar Client Security Fund (OSB CSF),
the claimant will:
a. Transfer to the Oregon State Bar all rights the claimant has against the lawyer or anyone else responsible for the
claimant's loss, up to the amount of the CSF award.
b. Cooperate with the OSB CSF in its efforts to collect from the lawyer, including providing information and testimony
in any legal proceeding initiated by the OSB CSF.
c. Notify the OSB CSF if the claimant receives notice that the lawyer has filed for bankruptcy relief.
d. Notify the OSB CSF if the claimant receives any payment from or otherwise recovers any portion of the loss from
the lawyer or any other person on entity and reimburse the OSB CSF to the extent of such payment.
10. Claimant’s Authorization
a. pRelease of Files: I hereby authorize the release to the OSB Client Security Fund, upon request, of any records or
files relating to the representation of me by the lawyer named in Question 2.
b. pPayment to Third Party: I hereby authorize the OSB Client Security Fund to pay all amounts awarded to me to:
Name: __________________________________________________________________________________________________
Address: _________________________________________________________________________________________________
Phone: __________________________________________________________________________________________________
11. Claimant's Signature and Verification
(Each claimant must have a notarized signature page . Please photocopy this page for each person listed in question 1.)
I HEREBY DECLARE THAT I HAVE READ THE RULES OF THE CLIENT SECURITY FUND
AND THE FOREGOING APPLICATION FOR REIMBURSEMENT; AND SUBMIT THIS CLAIM
SUBJECT TO THE CONDITIONS STATED THEREIN. I DECLARE THE INFORMATION WHICH I
HAVE PROVIDED IN THIS APPLICATION IS COMPLETE AND TRUE TO, THE BEST OF MY
KNOWLEDGE, INFORMATION, AND BELIEF. I UNDERSTAND THIS APPLICATION IS MADE
FOR USE IN OFFICIAL PROCEEDINGS AND IS SUBJECT TO PENALTY FOR PERJURY.
_____________________________________________________
Claimant's Signature
Dated this ____________
day of ________________________, 20____.
Please complete page 4 if an attorney is representing you for this claim.
6/ 18 • Page 3
You are not required to have an attorney in order to file this claim.
The CSF encourages lawyers to assist claimants in presenting their
claims without charge. A lawyer may charge a fee for such work
only if the following information is provided.
1. I authorize ____________________________________________________________________ (print name of attorney)
to act as my attorney in presenting my claim.
____________________________________________________
Claimant's Signature
2. I have agreed to act as the claimant's attorney: (check one below)
pWithout charge
pUnder the attached fee agreement
_______________________________________________________ _________________ _________________________
Attorney's Signature Attorney's Bar No. Attorney's Phone
_____________________________________________________________________________________________________
Attorney's Address
6/18 • Page 4
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Application for Reimbursement (Oregon State Bar)

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Completed 13 May 2021

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