KANSAS LAWYERS' FUND FOR CLIENT PROTECTION Kansas ...

KANSAS LAWYERS’ FUND FOR CLIENT PROTECTION
STATEMENT OF CLAIM
Please type or print legibly. All questions m ust be answ ered . Attach additional pages as
necessary. Sign the form, have your signature notarized and mail this claim form to the
Client Protection Fund Commission, Kansas Judicial Center - Room 374, 301 S.W. 10th
Avenue, Topeka, Kansas 66612-1507.
1. Name of Claimant(s) __________________________________________
First Middle Last
__________________________________________
First Middle Last
_____ Individual ____ Partnership ____ Corporation _____Other
(Describe if other) ______________________________________________________________
Address:
__________________________________________________________________
Street City State Zip
Phone: ___________________________ ______________________________
Home Number
Business Number
NOTE:
Occupation:
If you have any change of address or telephone number, please advise
the Fund of the change.
____________________________________________________________
____________________________________________________________
EMPLOYER
Social Secu rity No. or Federal Tax Id entification No.: ________________________
Date of Birth: _______________________________________________________
(Please provide the Social Security number and date of birth for each claim ant, if th ere is more than
one.)
2. Lawyer against whom claim is made:
Name: ___________________________________ __________________
Telephone
Address:
____________________________________________________________
Street City State Zip
2 Rev. 11/ 03