Funding Request Form

Online Lawsuit Funding Application

YOUR INFORMATION

YOUR ATTORNEY INFORMATION

Law Firm Contact (paralegal/legal assistant)

CASE INFORMATION

Date of Incident(s), Accident, or Injury

Name(s) of Defendant(s)

Describe Incident(s) / Accident / Cause of Injury

Describe your injuries

Describe the treatments you have received for your injuries

If you were working at the time of the incident, accident or injury, how much time did you miss from work because of the incident, accident, or injury?

Are you still out of work?

Did you receive an advance from another funding company on this case or any other case?

If Yes (Amount, Name of Funding Company, When Funded)

Are there any outstanding liens against you and/or the case? (medical, hospital, workman's

comp, disability, IRS, etc.)

Have you now or ever filed for bankruptcy?

If yes (When and Where)

Was the bankruptcy discharged? If so when?

Amount of Funding Requested

Authorization for Release of Information

By submitting this form, I agree that all the information listed is accurate and correct.
In order to obtain information about your case, we need your authorization to release your case records and information to us. We cannot proceed without it.

Enter your ATTORNEY'S NAME here

I request and authorize my attorney to provide Baric Enterprises Inc. with whatever information (whether oral or in writing) needed to evaluate my funding request. I specifically waive any privilege that I may have regarding such information.

I hereby request and authorize your firm to cooperate with and release to Baric Enterprises Inc. any and all information and documents pertaining to my case. Please share your opinion regarding this action with Baric Enterprises Inc. so that Baric Enterprises Inc. can evaluate my funding request.

I acknowledge that I understand the benefits and risks of non-recourse funding. I further acknowledge that I understand the effects of disclosing the contents of my file, including waiver of the attorney-client and work product privileges.


Thank you in advance for your cooperation.

Name (*)

Date (*)

 By clicking here, you indicate that you have read and agree to the Records Release Authorization. You must check this box for your application to be processed. This authorization gives us permission to contact your attorney and discuss your case with yourattorney.

By submitting this form I agree that all the information listed is accurate to the best of my knowledge.