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Submit this form for a FREE case evaluation based on the
information you provide.

— All information is NOT required.  Fill in as much as you can.
— All information will be kept strictly confidential.
— If there are privacy issues with us contacting you
 (Ex. "only call at night"), be sure to fill in Contact Notes.

Contact Information:
(You can supply specific contact instructions in"Notes")

Contact Name
Home Phone
Work Phone
FAX
E-mail
Contact Notes:
Client Information:
Client Name
US Citizen
Date of Birth
In Custody
Jail Name
Booking Number
Bail Amount
Prior Arrests
Case Information:
Charges/Accusations
Arrested
Arrest Date
Case Number
Court
Next Court Date
Case Facts: (Use as much space as you need)
Statement of the Case
Search and/or
Confession issues
Witness Issues
Other Defense Issues

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