Request for Assitance Online Submission Form


1. My Name *

2. My Address *

City, State Zip *

Daytime Telephone Number *

3. I wish The Mississippi Bar to consider this request for assistance with regard to the following lawyer(s)
Name

Address

City, State Zip

Telephone

4. Is this your lawyer?


5. Have you talked with the lawyer(s) named about the subject of this request?


6. I request assistance with regard to this lawyer because (Provide detailed statement of facts including dates and places)

7. I want the following assistance

8. Have you requested assistance or complained about this lawyer before?


If yes, please tell when and why

9. Are you willing to give evidence under oath about this matter?


If no, please explain why

10. Has any person lost any money, property, or other thing of value as a result of the events described above?


If yes, please explain

Signatures
Signature: (Entering your name here will represent your signature) *

Witness: (Entering your name here will represent your signature)


I understand that it may be necessary to act promptly to protect my rights and that commencement of a civil action may be required to preserve my rights. I acknowledge my understanding that the completion of this form does not constitute commencement of a civil action and that The Mississippi Bar will not commence any such action. I acknowledge it is my responsibility to seek and obtain any necessary legal advice with respect to this matter.

NOTICE: I UNDERSTAND THAT INFORMATION I SEND MAY BE USED TO ASSIST ME BUT MAY NOT BE CONFIDENTIAL

1: If you are submitting this Request for Assistance on behalf of or for another person, please give that person's name, address and daytime telephone number and explain why you are acting for that person.

2: If not, please tell us why not.  If yes, please provide the facts in 6 & 7 above