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STATEMENT OF CLAIM TO THE
CLIENT’S SECURITY FUND COMMITTEE
OF THE VERMONT BAR ASSOCIATION
 
(It is recommended by the Committee that you consult with an attorney in filing this claim.)
 
            1.      Name of claimant.
 
            2.      Address of claimant.
 
            3.      Telephone number of claimant.
 
            4.      Name of attorney whose conduct is alleged to have caused claimant’s loss.
 
            5.      Address of offending attorney.
 
            6.      State the date when you originally hired the offending attorney and the general nature of the business for which you hired him/her.
 
            7.      If you are presently represented by another attorney, state his/her name, address, and telephone number.
 
            8.      Indicate whether you have discussed this claim with your present attorney.
 
            9.      Describe the acts committed by the offending attorney which constitutes the basis for this claim.
 
            10.    State the total value of your loss by reason of the offending attorney’s acts, and describe whether your loss is in money, securities, real estate, or other property.
 
            11.    State the date or period of time when the acts were committed, and state when you sustained your loss.
 
            12.    State when you discovered your loss and describe the manner in which the loss came to your attention.
 
 
File Claim With:
Vermont Bar Association
Client Security Fund Committee
P.O. Box 100
Montpelier, VT 05601-0100