Client Questionnaire: Other Claims

Please enter all information as completely as possible.

Name:
Phone number:
Email address:
Please check any of the areas you feel apply to your case:
Housing discrimination : Environmental justice: Personal injury :
Describe person/organization who injured you, with relevant dates, and the persons involved:

What if any injuries did you sustain?:

	Please print a copy of this page for your records prior to clicking the submit button