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New Client Information Form
.
Please provide the information requested below. Additionally, please read and acknowledge McDannold Law's privacy policy regarding client Social Security Numbers.
CLIENT INFORMATION
*
Indicates required field
Last Name
*
First Name
*
Middle Name
*
Maiden Name
*
If applicable.
Sex
*
Male
Female
Date of Birth
*
Please enter DOB in MM/DD/YYYY format.
City of Birth
*
County of Birth
*
State of Birth
*
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
Washington D.C.
West Virginia
Wisconsin
Wyoming
American Samoa
Guam
Northern Marianas Islands
Puerto Rico
Virgin Islands
Other
Street Address
*
Please include your apartment number, if applicable.
City
*
County
*
State
*
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
Washington D.C.
West Virginia
Wisconsin
Wyoming
American Samoa
Guam
Northern Marianas Islands
Puerto Rico
Virgin Islands
Other
Zip
*
Social Security Number
*
Please provide in XXX-XX-XXXX format. For our Privacy Policy concerning client SSNs, please see the bottom of the page.
Driver License Number
*
Please enter exactly as shown on your Driver License, including any spaces or dashes.
State Issued
*
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
Washington D.C.
West Virginia
Wisconsin
Wyoming
American Samoa
Guam
Northern Marianas Islands
Puerto Rico
Virgin Islands
Other
E-Mail Address
*
Select All That Apply
*
I authorize e-mail communication about my case.
I authorize e-mail communication of general interest from McDannold Law.
I authorize follow-up telephone calls regarding my case.
Home Phone
*
Please provide in XXX-XXX-XXXX format.
Work Phone
*
Please provide in XXX-XXX-XXXX format.
Cell Phone
*
Please provide in XXX-XXX-XXXX format.
Place of Employment
*
If currently not employed, please enter "Not Applicable."
Job Title
*
Address of Employment
*
SPOUSE INFORMATION
Spouse's Full Name
*
Spouse's Address
*
Please provide your spouse's address, if different from your address.
Spouse's Maiden Name
*
If applicable.
Spouse's Employer
*
Please provide the name and address of your spouse's employer.
Spouse's Date of Birth
*
Please enter DOB in MM/DD/YYYY format.
Spouse's Phone
*
Please provide the best number at which to reach your spouse.
FINANCIAL RESPONSIBILITY
EMERGENCY CONTACT INFORMATION
Person Financially Responsible
*
Client (skip to next section)
Someone Else (complete this section)
Full Name of Responsible Person
*
Please provide the full name of the person financially responsible for legal fees.
DOB of Responsible Person
*
Please provide the Date of Birth of the financially responsible person.
Address of Responsible Person
*
Please provide the complete mailing address of the financially responsible person.
Phone of Responsible Person
*
Please provide the phone number of the financially responsible person.
SSN of Responsible Person
*
Please provide the Social Security Number of the financially responsible person.
DL Number of Responsible Person
*
Please provide the driver license number of the financially responsible person.
DL State of Issue
*
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
Washington D.C.
West Virginia
Wisconsin
Wyoming
American Samoa
Guam
Northern Marianas Islands
Puerto Rico
Virgin Islands
Other
Please provide the state that issued the financially responsible person's driver license.
Full Name of Emergency Contact
*
Address of Emergency Contact
*
Please provide the complete mailing address of your emergency contact.
Cell Phone of Emergency Contact
*
Other Phone of Emergency Contact
*
Purpose of Visit
*
Please describe your reason for coming to McDannold Law.
Have you consulted another attorney in this matter?
*
Select
Yes
No
Do you currently have a will, trust, or other Estate Planning document?
*
Select
Yes
No
Unsure
Have you been denied Social Security benefits?
*
Select
Yes
No
Have you been denied Veterans benefits, or been rated incorrectly?
*
Select
Yes
No
Unsure
How were you referred to McDannold Law?
*
PRIVACY POLICY REGARDING CLIENT SOCIAL SECURITY NUMBERS
Social Security information will only be used in the event you hire the firm to represent you in your legal matter, and then only when necessary during the course of your case.
Social Security numbers are collected by the law firm from the client, and all clients provide such information to the firm in writing.
Social Security numbers are most often used to positively identify parties. Some uses may include initial service, in court orders, in required reports filed with the State of Florida, or to obtain retirement or other information from third parties. Most courts require the Social Security numbers of all parties.
All information received from a client is confidential. Numbers are not released from the firm unless authorized by the client or required in the course of representation as stated herein.
The employees of McDannold Law have access to this personal information.
Every step is taken to protect your privacy. This information is kept secure within the offices of the firm in file folders and file drawers until such time that the file information is archived. Client files will be shredded in accordance with the firm’s record retention policy after the time required by the Florida Bar to maintain such records has expired. Social Security numbers are also securely maintained in firm software programs, all of which are encrypted and/or password protected.
By clicking the "SUBMIT" button below, I acknowledge that I have read the above privacy information provided by McDannold Law regarding the use of my Social Security number.
Submit
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