To the office of court administration of the state of______
1. Date of agreement as to retainer _______________________
2. Terms of compensation __________________________________
3. Name and home address of client ________________________
4. If engaged by an attorney, name and office address of retaining attorney__________
5. If claim for personal injuries, wrongful death or property damage, date and place of occurrence _______
6. If a condemnation or change of grade proceeding:
(a) Title and description ______________
(b) Date proceeding was commenced ______
(c) Number or other designation of the parcels affected _________
7.Name, address, occupation and relationship of person referring the client____________
Dated: _________,
Address: _______ day of ________,_______
Yours etc
Signature of Attorney
___________________
Attorney
___________________
Office and P.O. Address
_____Dist.___Dept. __County
