Form JD-GC-15 "Application for Reimbursement - Client Security Fund" - Connecticut

What Is Form JD-GC-15?

This is a legal form that was released by the Connecticut Judicial Branch - a government authority operating within Connecticut. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on January 1, 2015;
  • The latest edition provided by the Connecticut Judicial Branch;
  • Easy to use and ready to print;
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  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form JD-GC-15 by clicking the link below or browse more documents and templates provided by the Connecticut Judicial Branch.

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Download Form JD-GC-15 "Application for Reimbursement - Client Security Fund" - Connecticut

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APPLICATION FOR REIMBURSEMENT
STATE OF CONNECTICUT
ADA NOTICE
CLIENT SECURITY FUND
JUDICIAL BRANCH
The Judicial Branch of the State of Connecticut complies with the
Americans with Disabilities Act (ADA). If you need a reasonable
www.jud.ct.gov
JD-GC-15 Rev. 1-15
accommodation in accordance with the ADA, contact a court
P.B. §§ 2-68, 2-70 through 2-78
clerk or an ADA contact person listed at www.jud.ct.gov/ADA.
Instructions
1. Review the information contained in the pamphlet The Client Security Fund Answers to Your Questions (Form JDP-GC-16) before completing this form.
The pamphlet is available from the office of the Client Security Fund Committee or online at http://www.jud.ct.gov/Publications/GC016.pdf.
2. Provide the following information requested as completely as possible. If more space is needed, attach additional pages.
3. Submit copies of any documentation that you believe proves your loss, such as cancelled checks, receipts, letters, closing statements, etc. with your
completed form. Do not submit original documents, as they will be made part of the file and will not be returned.
4. The form must be signed by you, and any other named claimant, under oath before a notary public or other authorized official.
5. Mail the completed application, and any supporting documents, to the address shown below. Applications that are incomplete may be returned without
further review.
To: Client Security Fund Committee, 2nd Floor, Suite One, 287 Main Street, East Hartford, CT 06118-1885
Your Name (First, Middle, Last)
1.
Mr.
Ms.
Other
Address (Number, street, town and zip code)
E-mail Address
Telephone Number
2. Name, address and telephone number of the attorney whom you claim dishonestly and/or fraudulently has taken your
money or property:
3. What legal services did you ask this attorney to perform for you?
Please note that the fund may only reimburse losses that occurred in the
course of an attorney-client relationship or in a fiduciary capacity arising out of an attorney-client relationship.
4. Describe the attorney's dishonest and/or fraudulent conduct
(attach additional pages if necessary). Please note that in order for a claim to
be reimbursable, it must involve conduct on the part of your attorney in the nature of a theft, embezzlement or the wrongful taking of money or property. In
limited circumstances the committee may reimburse a loss based on an attorney's refusal to refund unearned fees paid in advance. Losses that are the
result of negligence, malpractice, or investment services provided by the attorney are not covered by the client security fund:
5. State the amount of loss you claim should be reimbursed by the client security fund:
6. Did your loss involve:
Money
Securities
Other property (Specify below):
(“X” proper box or boxes)
7. Can your loss be reimbursed from any other source, such as insurance, fidelity bonds or surety agreements?
(“X” proper box)
No
Don't know
Yes (If yes, describe this source below):
8. How much did you pay this attorney?
(Please include copies of any documents that are evidence of your payment or payments)
9. Did you have a written fee agreement with the attorney?
(If yes, attach a copy of the agreement.)
(Page 1 of 2)
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APPLICATION FOR REIMBURSEMENT
STATE OF CONNECTICUT
ADA NOTICE
CLIENT SECURITY FUND
JUDICIAL BRANCH
The Judicial Branch of the State of Connecticut complies with the
Americans with Disabilities Act (ADA). If you need a reasonable
www.jud.ct.gov
JD-GC-15 Rev. 1-15
accommodation in accordance with the ADA, contact a court
P.B. §§ 2-68, 2-70 through 2-78
clerk or an ADA contact person listed at www.jud.ct.gov/ADA.
Instructions
1. Review the information contained in the pamphlet The Client Security Fund Answers to Your Questions (Form JDP-GC-16) before completing this form.
The pamphlet is available from the office of the Client Security Fund Committee or online at http://www.jud.ct.gov/Publications/GC016.pdf.
2. Provide the following information requested as completely as possible. If more space is needed, attach additional pages.
3. Submit copies of any documentation that you believe proves your loss, such as cancelled checks, receipts, letters, closing statements, etc. with your
completed form. Do not submit original documents, as they will be made part of the file and will not be returned.
4. The form must be signed by you, and any other named claimant, under oath before a notary public or other authorized official.
5. Mail the completed application, and any supporting documents, to the address shown below. Applications that are incomplete may be returned without
further review.
To: Client Security Fund Committee, 2nd Floor, Suite One, 287 Main Street, East Hartford, CT 06118-1885
Your Name (First, Middle, Last)
1.
Mr.
Ms.
Other
Address (Number, street, town and zip code)
E-mail Address
Telephone Number
2. Name, address and telephone number of the attorney whom you claim dishonestly and/or fraudulently has taken your
money or property:
3. What legal services did you ask this attorney to perform for you?
Please note that the fund may only reimburse losses that occurred in the
course of an attorney-client relationship or in a fiduciary capacity arising out of an attorney-client relationship.
4. Describe the attorney's dishonest and/or fraudulent conduct
(attach additional pages if necessary). Please note that in order for a claim to
be reimbursable, it must involve conduct on the part of your attorney in the nature of a theft, embezzlement or the wrongful taking of money or property. In
limited circumstances the committee may reimburse a loss based on an attorney's refusal to refund unearned fees paid in advance. Losses that are the
result of negligence, malpractice, or investment services provided by the attorney are not covered by the client security fund:
5. State the amount of loss you claim should be reimbursed by the client security fund:
6. Did your loss involve:
Money
Securities
Other property (Specify below):
(“X” proper box or boxes)
7. Can your loss be reimbursed from any other source, such as insurance, fidelity bonds or surety agreements?
(“X” proper box)
No
Don't know
Yes (If yes, describe this source below):
8. How much did you pay this attorney?
(Please include copies of any documents that are evidence of your payment or payments)
9. Did you have a written fee agreement with the attorney?
(If yes, attach a copy of the agreement.)
(Page 1 of 2)
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10. Describe what steps you have taken to recover the loss directly from the attorney, or any other source. Provide the date
or dates when you took such steps (for example, if you filed a civil action, provide the date the action was filed):
11. State the date when the loss of your money or property occurred (State how and when your loss was discovered):
Please note that a loss presented more than four years after the loss was discovered or should have been discovered ordinarily is not reimbursable by
the client security fund:
12. Answer the following questions to the best of your knowledge
("X" proper box)
Please note that losses are not covered by the client
security fund unless you have been awarded a judgment against the attorney, or the attorney that caused the loss has died, been adjudged incapable,
been disbarred or suspended from the practice of law, has resigned from the practice of law, or been placed on probation or inactive status:
a. Has the attorney died? ..........................................................
No
Yes, give date:
Unknown
b. Has the attorney been adjudged incapable? ...........................
No
Yes, give date:
Unknown
c. Has the attorney been disbarred or suspended from the
No
Yes, give date:
Unknown
practice of law?.....................................................................
d. Has the attorney resigned from the practice of law? ................
No
Yes, give date:
Unknown
e. Has the attorney been placed on probation or inactive status
No
Yes, give date:
Unknown
by a Connecticut court?.........................................................
f. Have you been awarded a judgment against the attorney? ......
No
Yes, give date:
Unknown
(“X” proper box
13. This loss has been reported to:
State's Attorney
Police
Statewide Grievance Committee
or boxes)
Attach a copy of your complaint and describe what action was taken.
14. State the names and addresses of any witnesses or individuals having information concerning your claim:
Name of Witness or Individual 1
Name of Witness or Individual 2
Address of Witness or Individual 1 (Number, street, town and zip code)
Address of Witness or Individual 2 (Number, street, town and zip code)
Telephone Number of Witness or Individual 1
Telephone Number of Witness or Individual 2
15. Are you related to the attorney you claim caused your loss, or are you an associate, partner, or employee of the attorney?
No
Yes
(If yes, state your relationship with the attorney):
16. Name, address and telephone number of your present attorney:
Notice
The Practice Book rules governing claims filed with the Client Security Fund Committee do not permit attorneys who help clients process
claims with the Fund to charge legal fees for that service, except with the permission of the Client Security Fund Committee. If it is
determined that you should be reimbursed by the client security fund, you will be required to sign a document transferring your claim
against the attorney to the Client Security Fund Committee, to the extent of the award made to you. By signing below, you agree to
cooperate in the investigation of your claim and in the investigation of any related disciplinary or criminal proceedings, and you agree to
cooperate with the Client Security Fund Committee in any action undertaken to recover amounts paid to you from the client security fund.
I, the undersigned, under oath say: I am the claimant in the above matter; I have read the foregoing and know the
contents thereof; and I certify that the same is true of my own knowledge, except as to the matters and things which
are therein stated upon my information and belief, and that as to those matters and things, I believe them to be true.
Signed (Claimant)
Date signed
u
Date
At (Town)
Signed (Commissioner of Superior Court, Notary Public)
Subscribed and sworn
to before me on:
(Page 2 of 2)
JD-GC-15 Rev. 11-14 (Back/Page 2)
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