THE NORTH CAROLINA STATE BAR
CLIENT SECURITY FUND
APPLICATION FOR REIMBURSEMENT
Instructions
Please answer every question. If more space is needed, attach additional pages.
Mail the completed application and Subrogation Agreement to: Client Security Fund Board, North
Carolina State Bar, P.O. Box 25908, Raleigh, North Carolina 27611-5908. Telephone number
(919) 828-4620.
It is important that you submit all evidence that proves your loss, such as canceled checks,
receipts, letters, settlement statements, closing statements, etc.
Please print or type this application.
1. Your name: ________________________________________________________________
2. Your address: ______________________________________________________________
City:_________________________________________State:_________Zip:__________________
3. Your telephone numbers: (Work)_______________________(Home)_________________
(Mobile)______________________________________________________________________
4. Your email address: _________________________________________________________
5. Name office telephone number of any attorney representing or assisting you with this application:
(It is not necessary for you to be represented by counsel. The Fund does not pay fees charged by an
attorney for representing an applicant.)
__________________________________________________________________________________
6. Name, address and office telephone number of attorney who you believe dishonestly took your
money or property:
___________________________________________________________________________________
___________________________________________________________________________________
7. What amount of money or what property did you lose because of the dishonest acts of the accused
attorney:
Money: ________________________________________________________________________
Property: _______________________________________________________________________
8. If you know, the date the loss occurred: ____________________________________________
9. Date you discovered the loss and how you discovered it: _______________________________
_____________________________________________________________________________
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If you are not seeking reimbursement for legal fees, go to question 11.
10. Are you seeking reimbursement for legal fees paid to the accused attorney? _______________ If
so, please send us the attorney’s file if you have it and answer the following questions.
(a) Approximately when did you hire the accused attorney? ______________________________
(b) What legal services was the accused attorney hired to perform for you? __________________
______________________________________________________________________________
(c) In what county was the attorney’s legal work to be filed? ____________________________
(d) What was the fee agreement for those services? _____________________________________
______________________________________________________________________________
(e) Was the fee agreement in writing? _______________If so, please attach a copy of the agreement.
(f) How much did you pay the accused attorney and when did you make the payment(s)? (Please attach
copies of any evidence of payments and copies of billing statements you have.)
__________________________________________________________________________________
(g) Did you pay court costs or filing fees in advance? _________________If so, how much?
$______________
(h) Describe as best you can recall each time you met with the accused attorney and what happened.
Provide any available documentation.__________________________________________________
__________________________________________________________________________________
(i) Describe as best as you can recall each time you discussed your matter by telephone with the accused
attorney. Provide any available documentation. _____________________________________________
___________________________________________________________________________________
(j) What legal papers, if any, did the accused attorney prepare for you? If legal papers were filed with
the court, provide case number and location of court. ______________________________________
__________________________________________________________________________________
(k) Describe any court appearances the accused attorney made for you.
_________________________________________________________________________________
(l) What is the status of your legal matter at this time? _________________________________
(m) Do you have a new attorney to complete your legal matter? __________If so, please give the name
and address of the new attorney. ________________________________________________________
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11. In chronological order, give a detailed statement of the dishonest act(s) on which your claim is
based. (Please attach copies of all relevant documents such as the accused attorney’s file, canceled
checks, receipts, agreements, settlement statements, correspondence, etc.)
_________________________________________________________________________________
__________________________________________________________________________________
12. Names, addresses and telephone numbers of other persons who may have knowledge about the loss
who might be witnesses for you:
___________________________________________________________________________________
___________________________________________________________________________________
13. At the time of the dishonest conduct, were you related by blood or marriage to the accused attorney,
or a partner or associate of the accused attorney, or in business with the accused attorney, or an
employee of the accused attorney? ______________________ If so, please explain:
__________________________________________________________________________________
14. Please describe all efforts you have made to collect the amount claimed from the accused attorney
(e.g., telephone calls, demand letters, lawsuit, etc.). Please attach copies of all relevant documents.
_________________________________________________________________________________
15. Do you know if the accused attorney was bonded or had malpractice or other insurance which might
cover the loss? ______________________ If so, what is the name and address of the insurance
company (ies)?
___________________________________________________________________________________
16. Have you made any claim against any bond or malpractice or other insurance policy of the accused
lawyer? _____________________If so, describe your efforts and the insurance company’s response.
__________________________________________________________________________________
___________________________________________________________________________________
17. Do you have any insurance, bond or agreement that may pay for the loss?________________ If so,
please describe the name and address of the insurance company, the type of coverage, the policy
number, the steps you have taken to make a claim and the insurance company’s response.
___________________________________________________________________________________
___________________________________________________________________________________
18. If the loss occurred in a real estate transaction, have you pursued a claim under the insured closing
letter issued by the title insurance company listed on the HUD-1 for the closing? Please attach a copy
of the HUD-1.
___________________________________________________________________________________
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19. If you have been reimbursed by anyone for any or all of your loss, state the amount received by
you, the person(s) who made the payment, and the date of the payment(s).
Amount By Whom Paid Date of Payment
$_________________ _________________________________________ ________________
$_________________ _________________________________________ ________________
20. To your knowledge have any civil, criminal or other proceedings been brought against the accused
attorney based on the same facts as contained in this application? ___________________ If so, state by
whom, where, file number, and the status of those proceeding(s). If not, to your knowledge are such
proceedings planned?
___________________________________________________________________________________
___________________________________________________________________________________
21. Has the accused attorney acknowledged to you that you have a valid claim? ______________ If so,
please explain and provide any documentation.
___________________________________________________________________________________
___________________________________________________________________________________
22. State any other facts that you believe would be important to the Board when it considers your claim.
___________________________________________________________________________________
************
State of _________________________________ County of _____________________________
The undersigned, being first duly sworn, says: I am the applicant in the above matter; I have read the
foregoing Application for Reimbursement, and know the contents thereof; and I certify that the same
is true of my own knowledge.
_____________________________________ _________________________________
Signature of Applicant Signature of Co-Applicant
Subscribed and sworn to (or affirmed) before me this _____ day of _____________________, 2____.
_____________________________________
(Notary Public Signature)
My commission expires: ____________________________
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THE NORTH CAROLINA STATE BAR
CLIENT SECURITY FUND
Subrogation Agreement
A. The undersigned applicant has signed and submitted an application to induce the Client Security
Fund (the “Fund”) to process and investigate a claim and to consider reimbursement of all or part of
the loss incurred by the applicant as a result of the dishonest conduct of the accused lawyer.
B. Upon payment by the Fund of all or any portion of the loss, applicant, in consideration of such
payment:
1 transfers, assigns, and sets over to the North Carolina State Bar, as subrogee, all of applicant’s
claims and demands against and rights to sue the accused attorney arising out of the dishonest
acts described in this application (the “Subrogated Claims”);
2 authorizes the North Carolina State Bar to pursue all Subrogated Claims against the accused
attorney, either in the name of the applicant, in the State Bar’s name, or both, as the State Bar in
its sole judgment deems advisable;
3 agrees to cooperate with the North Carolina State Bar in: (a) enforcing any Subrogated Claim,
(b) the investigation of this claim, and (c) the investigation and prosecution of any related
disciplinary proceedings against the accused attorney;
4 agrees to repay the Fund, up to the amount paid to the applicant by the Fund plus expenses, any
amounts based on this claim subsequently received by applicant from any source other than the
Fund; and,
5 agrees to assign to the North Carolina State Bar any judgments obtained by applicant against
the accused attorney arising out of the attorney’s dishonest conduct.
C. The applicant understands that:
1 all civil actions against the accused attorney shall be under the control of the North Carolina
State Bar and the State Bar may prosecute, fail to prosecute, or abandon any such action against
the accused attorney as the State Bar may deem appropriate in its sole discretion and without
the necessity of the consent or approval of the applicant; and
2 should the applicant receive an award from the Fund, the facts relating to the loss become a
matter of public record.
3 IN ESTABLISHING THE CLIENT SECURITY FUND PURSUANT TO ORDER OF THE
SUPREME COURT OF NORTH CAROLINA, THE NORTH CAROLINA STATE BAR DID
NOT CREATE OR ACKNOWLEDGE ANY LEGAL RESPONSIBILITY FOR THE ACTS
OF INDIVIDUAL ATTORNEYS IN THE PRACTICE OF LAW. ALL REIMBURSEMENTS
OF LOSSES FROM THE CLIENT SECURITY FUND SHALL BE A MATTER OF GRACE
IN THE SOLE DISCRETION OF THE BOARD ADMINISTERING THE FUND AND NOT
A MATTER OF RIGHT. NO APPLICANT OR MEMBER OF THE PUBLIC SHALL HAVE
ANY RIGHT IN THE CLIENT SECURITY FUND AS A THIRD PARTY BENEFICIARY
OR OTHERWISE.
Signed the ____________ day of ________________________________ 2______.
_____________________________ ________________________________
Signature of Applicant Signature of Co-Applicant