Intake Form
Your Information
Your Name:
Your Email Address:
Address:
City / State / Zip
Phone Number
Fax Number
Federal I.D. Number or your Soc sec No:
Your Employment Position:
Who Referred You to This Office ?:
Debtor Information
Type of Debtor:
Name of Debtor:
Debtor Address:
City / State / Zip
Phone:
Fax:
Guarantor Information
Name of Guarantor
(If Any):
Address: (if known)
City / State / Zip
Phone:
Amount of Debt owed:
Do you have a Written Contract with the Debtor:
Describe how the Debt was incurred:
Do you have any documents which support you position?:
If so describe them below:
Witness Information
Name of Witness:
Phone:
Home Address: (if known)
City / State / Zip
Name of Witness:
Phone:
Home Address: (if known)
City / State / Zip
Acknowledgment - Send Information
Please read
statement
at right and
check box
to proceed.

By checking the box to the left, I acknowledge that I understand that the Law Offices of Rosen and Zimmerman, APLC has not agreed to represent me in any matter and that in the event an offer of representation is made I will be offered a written retainer agreement signed by either Howard S. Rosen or Paul S. Zimmerman which will define the scope of my representation and the obligations of the parties. Furthermore I understand that if representation is offered and accepted I will be charged between 5% and15% of the debt owed depending on the debt amount as a retainer plus 25% of any judgment or recovery obtained. In the event a law suit is filed I will be charged an additional fee of up to $250.00 to cover the cost of the court's filing fee and service of process.
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