Probono Legal Request

PROBONO LEGAL REQUEST

This Probono Legal Request (the Request) is submitted on Date of Request: by Client Name: (Applicant) to Provider Name: (Provider).

Applicant requests that Provider consider providing pro bono legal assistance in accordance with Provider's intake policies and the terms set forth below.

RECITALS

WHEREAS, Applicant desires legal assistance concerning the matter described below and represents that Applicant lacks sufficient resources to pay for legal representation; and

WHEREAS, Provider administers or participates in a pro bono legal program and may, in its discretion, accept eligible matters for representation without fee subject to internal conflict checks, resource availability, and eligibility verification; and

WHEREAS, Applicant submits documentary information and certifications to allow Provider to evaluate eligibility and potential representation.

NOW, THEREFORE, in consideration of the mutual promises and covenants contained herein, the parties agree as follows:

1. PURPOSE

The purpose of this Request is to allow Provider to evaluate Applicant's eligibility for pro bono legal services and to document Applicant's authorization for the limited purposes described in this Request. Submission of this Request does not create an attorney-client relationship. An attorney-client relationship will be formed only if Provider issues a written engagement acceptance.

2. NATURE OF MATTER AND CONTACT INFORMATION

3. ELIGIBILITY, CERTIFICATIONS, AND FINANCIAL INFORMATION

Applicant certifies under penalty of perjury that all information provided in this Request, including financial information and documentary attachments, is true, complete, and correct to the best of Applicant's knowledge. Applicant acknowledges that Provider will rely on these representations in determining whether to accept representation.

Applicant authorizes Provider and its designated representatives to obtain and review records directly relevant to the determination of eligibility and conflict analysis, including but not limited to credit reports, public records, court records, and benefit statements, as necessary for intake and screening. Applicant acknowledges that the scope of any such inquiry will be limited to matters relevant to eligibility and conflicts.

4. SCOPE OF POTENTIAL REPRESENTATION

If Provider accepts the matter, Provider will provide only those legal services specifically identified in a written engagement letter. Provider may limit services to advice, brief services, negotiation, settlement, litigation, or referral. Applicant understands that Provider is not obligated to provide continuing representation beyond the scope expressly accepted in writing.

5. CONFLICTS AND WITHDRAWAL

Acceptance is subject to Provider's conflict check. Provider may decline or withdraw from representation if a conflict arises, if material misrepresentations are discovered, or if Applicant fails to cooperate or meet eligibility requirements. Provider will provide reasonable notice when withdrawal is necessary and will take steps to avoid foreseeable prejudice to Applicant's interests consistent with professional obligations.

6. CONFIDENTIALITY

Information shared during the intake process will be treated as confidential to the extent required by law and professional rules. No attorney-client relationship or privilege is created by submission of this Request alone. If Provider agrees in writing to represent Applicant, communications after engagement will be subject to attorney-client privilege and confidentiality protections.

7. FEES, COSTS, AND REIMBURSEMENT

Pro bono legal services are provided without attorney fees. Applicant may be responsible for external costs or filing fees if applicable; such responsibility will be set forth in any written engagement agreement. Provider may, at its discretion and with Applicant's consent, seek to recover costs from third parties or recoverable sources.

8. TERMINATION

Either party may terminate or withdraw from the engagement in accordance with applicable law and professional rules. Termination of representation does not relieve Applicant of obligations incurred prior to termination as set forth in any engagement letter.

9. NOTICES

All notices required or permitted under this Request shall be in writing and delivered to the contact information provided by the parties. Notice by email shall be effective upon transmission unless the sending party receives notice of non-delivery.

10. GOVERNING LAW

This Request shall be governed by and construed in accordance with the laws of the state in which Provider maintains its primary office for pro bono matters, without regard to conflict of law principles.

11. ENTIRE AGREEMENT; SEVERABILITY

This Request, together with any subsequently executed written engagement agreement, constitutes the entire agreement between the parties concerning the matters described herein. If any provision of this Request is held invalid or unenforceable, the remainder of this Request shall remain in full force and effect.

12. AMENDMENTS; WAIVER; COUNTERPARTS

Any amendment to this Request must be in writing and signed by both parties. Failure to enforce any right shall not constitute a waiver of future enforcement. This Request may be executed in counterparts, each of which shall be deemed an original.

13. CERTIFICATION AND AUTHORIZATION

By signing below, Applicant certifies that the information provided in this Request is true and complete, authorizes Provider to verify the information provided, and acknowledges that submission of this Request does not guarantee that Provider will accept the case for pro bono representation.

ADDITIONAL INFORMATION

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