CLIENT DATA SHEET – CIVIL CASE
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Case number:___________________ Client is: Plaintiff Defendant Client is: Person(s) Business Entity |
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Client is: Sole Client Main Client of Group numbering:_____ Client #______ of this group Member of Class Action |
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Name: SSN: Sex: |
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DOB:___/___/___ POB: Religion: |
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Address: Apt/Ste: Cmp/Sb: |
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City: Co: St: Zip: -- Own/Rnt/Rsd:Yrs: |
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Phones: (H): ( ) - Cell Phone: ( ) - |
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E-Mail: Website: |
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Place of Employment: Title: Supervisor: |
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Nature of work: |
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Address: Reachable at work? Y / N |
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City: St: Zip: -- |
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Phone:( ) - X Cell Phone: ( ) - |
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E-Mail: Website: |
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Phone: (others): type: ( ) - ( ) - |
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Client-Provided Background: |
Releases: |
Client: |
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Documentation Physical Evidence Printed Articles Television Website: __________________ Other:_____________________ |
All Info – Client All Info - Spouse All Info – Child Power of Atty Subpoena Other:________ |
Criminal history Litigation history No Civil/Crim History Witness lists Official Reports ______________ |
Date of first contact: ___/___/___ Referred by:_____________________ Contract / Agreement signed ___/___/___ Retainer Credit Application Deposition taken: ___/___/___ Deposition Bates #: |
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Full “Subject Data File” started on Client, Full background check performed, History Sheet filled out |
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Suit Filed or Summons rec’d on: ___/___/___ Via: Reviewed on: ___/___/___ By: |
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Case Synopsis: |
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Extended narrative attached |
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Acceptable Settlement for Arbitration / Negotiation: |
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Client Releases and Acknowledgement: (check the “R” box if separate form used) |
R |
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I hereby authorize release of any and all psychological records pertaining to this case. Initial:_____ |
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I hereby authorize release of any and all medical and dental records pertaining to this case. Initial:____ |
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I hereby authorize release of any and all criminal records pertaining to this case. Initial:______ |
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I hereby authorize release of any and all credit and financial records pertaining to this case. Initial:_____ |
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I hereby authorize release of any and all DMV records pertaining to this case. Initial:_____ |
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I hereby certify that all information presented above is true, correct, and complete, and give full authorization for a full and complete background check on myself and all aspects of my case. I understand this check will include any and all records listed above.
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Client:__________________________________ Signature:_______________________________ Date:___/___/___ |
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Witness:________________________________ Signature:_______________________________ Date:___/___/___ |
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Document Control #:______________________ File Name:_____________________________ |
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