Miami Law Investor Rights Clinic

Client Eligibility Questionaire

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Your Name: (Required)  

Address:  

City, State, Zip Code:  

Daytime Phone:  

Evening Phone:  

Cell Phone:  

E-mail Address: (Required)

1. Did the transaction(s) complained of occur within the past six years?

Yes No

2. Please provide a brief description of your dispute with your broker-dealer. Specifically, please provide a brief answer to the following questions:

a. What is the nature of the transaction(s) at issue?

b. What amount of money is involved in the transaction?

c. What is the name and address of your broker?

d. Is your broker registered?

Yes No

e. What specific complaint(s) do you have about your broker or brokerage firm?

f. What kinds of records do you have that relate to the transaction at issue? You may, but need not attach copies of any records that you have. (You will need these records to pursue your claim, so it is a good idea to gather them now.)

3. Have you attempted to contact the broker or the firm to resolve this dispute? If so, what was the result of your contact?

4. What is the amount of money that you are seeking from the broker-dealer?

5. What is your household's annual income? (If you are invited to interview at the Clinic, you will be asked to provide copies of your federal tax returns for the past two years.)

6. Do you have any major assets other than your residence and a car? If so, please describe them.

7. Previous legal counsel involved:

a. Have you already consulted with an attorney regarding the transaction at issue who declined to represent you?


Yes No

b. If your answer is YES, please provide the names, addresses, and telephone numbers of the attorney(s) you have consulted about this claim and who have declined to represent you, because of the amount involved or nature of the claim:

8. Are you 65 or older?

Yes No

9. Are you a Florida resident?

Yes No

10. Where did you live during the transaction(s) at issue?

11. What is the source of referral to the Investor Rights Clinic?



CLIENT ELIGIBILITY QUESTIONNAIRE

Access an online version the client questionnaire and submit electronically.

PDF iconView a printable version of the questionnaire.


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PDF iconCuestionario de Elegibilidad
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