MALP 0024 12 12 Page 2 of 2
MALP 0024 (PI) (FL) 12 12
4. Dual or Multiple Representations - Check each box below if, at any time during the past two
(2) years, you have represented or provided any kind of legal service to any of the dual or
multiple parties shown below, relative to the same basic real estate matter or transaction.
Please attach a detailed description relative to each box that is checked, including a description
of any actions you took to address any potential conflict of interests issues or exposures.
Dual or multiple investors, owners, partners or joint venturers
General Partner and Limited Partner
5. During the past two (2) years, have any of the following situations occurred? Please attach a
detailed description relative to any "Yes" answer. Have you:
a. Provided any legal service, or other service to any past or present client, or on any
commercial land or property or development project, that has gone into, or become the
subject of, any kind of litigation involving buyer, seller, or lender, or any foreclosure, sheriff's
sale, receivership, trusteeship, liquidation, or any voluntary or involuntary bankruptcy
Yes No
b. Performed any service or rendered any advice or any opinion relative to any financial,
economic, appraisal or valuation analysis or opinion for a client or any other party?
Yes No
c. Accepted compensation for legal or other services on the basis of a commission or
percentage of the dollar value or sale price of any transaction?
Yes No
I understand the information submitted herein becomes a part of my Professional Liability Insurance Application and is
subject to the same warranty and conditions.
Any person who knowingly and with intent to defraud any insurance company or other person files an application for
insurance containing any false information, or conceals for the purpose of misleading, information concerning any fact
material thereto, commits a fraudulent insurance act.
______________________________ ____________________________ ______________________________
Signature of Owner, Officer or Partner Print or Type Name and Title Date (month-day-year)
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signature
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