PERSONAL INJURY QUESTIONAIRE AND CONTRACT FOR ATTORNEY SERVICES

INSTRUCTIONS

Download, fill out, and print the questionare and attorney fee agreement below.
Attach relevant documents.
Fax or mail the questionare, agreement, and other documents to our office.
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After we have received the documents and your payment, we will take it from there and will call you if we need anything more from you.

If you have questions or would like us to fax or mail you a questionare, give us a call at (562) 596-8177, send us a fax at (562) 596-0298, E-mail us at KinseyE@ix.netcom.com.

PERSONAL QUESTIONARE

ATTORNEY FEE AGREEMENT

PAYMENT OPTIONS

PERSONAL INJURY QUESTIONIARE

SECTION 1 CLIENT INFORMATION
*NAME & ADDRESS*
NAME/ADDRESS:	_____________________________________________ _____________________________________________ _____________________________________________ _____________________________________________
COUNTY:	_____________________________________________
HOME PHONE:	(_____) _____ - __________
BUSINESS PHONE:	(_____) _____ - __________
FAX:	(_____) _____ - __________
E-MAIL:	________________________

*EMPLOYMENT*
EMPLOYER NAME & ADDRESS:	_____________________________________________ _____________________________________________ _____________________________________________ _____________________________________________
HOW LONG WITH THIS EMPLOYER?	_____________________________________________
*GENERAL INFORMATION*
BIRTHDAY:	_____________________________________________
SOCIAL SECURITY #:	_____________________________________________
DRIVER'S LIC. #:	_____________________________________________
LENGTH RESIDENCE IN CA:	_____________________________________________
LENGTH RESIDENCE IN COUNTY:	_____________________________________________

SECTION 2 INFORMATION ABOUT YOUR SPOUSE
*SPOUSE NAME & ADDRESS*
NAME/ADDRESS:	_____________________________________________ _____________________________________________ _____________________________________________ _____________________________________________
COUNTY:	_____________________________________________
HOME PHONE:	(_____) _____ - __________
BUSINESS PHONE:	(_____) _____ - __________
FAX:	(_____) _____ - __________
E-MAIL:	________________________

*SPOUSE EMPLOYMENT*
EMPLOYER NAME & ADDRESS:	_____________________________________________ _____________________________________________ _____________________________________________ _____________________________________________
HOW LONG WITH THIS EMPLOYER?	_____________________________________________
*SPOUSE - GENERAL INFORMATION*
BIRTHDAY:	_____________________________________________
SOCIAL SECURITY #:	_____________________________________________
DRIVER'S LIC. #:	_____________________________________________
LENGTH RESIDENCE IN CA:	_____________________________________________
LENGTH RESIDENCE IN COUNTY:	_____________________________________________

SECTION 3 MARRIAGE & SEPARATION
*MARRIAGE*
DATE OF MARRIAGE:	_____________________________________________
PLACE OF MARRIAGE:	_____________________________________________
*SEPARATION*
DATE OF SEPARATION:	_____________________________________________
DATE OF SEPARATION:	_____________________________________________

SECTION 4 MINOR CHILDREN
*CHILDREN OF THIS MARRIAGE*
FULL LEGAL NAME	BIRTHDATE	AGE
1. ______________________________________________ Living With Whom? ___________________________ Residence Address: ___________________________	____________	______
2. ______________________________________________ Living With Whom? ___________________________ Residence Address: ___________________________	____________	______
3. ______________________________________________ Living With Whom? ___________________________ Residence Address: ___________________________	____________	______
4. ______________________________________________ Living With Whom? ___________________________ Residence Address: ___________________________	____________	______
*CHILDREN NOT OF THIS MARRIAGE*
FULL LEGAL NAME	BIRTHDATE	AGE
1. ______________________________________________ Living With Whom? ___________________________ Residence Address: ___________________________	____________	______
2. ______________________________________________ Living With Whom? ___________________________ Residence Address: ___________________________	____________	______
3. ______________________________________________ Living With Whom? ___________________________ Residence Address: ___________________________	____________	______

SECTION 5
INCOME & EXPENSE INFORMATION

*
GENERAL INFORMATION
*

1. Are you receiving or have you applied for or do you intend to apply for welfare or AFDC?

____ Receiving ____ Applied For ____ Intend To Apply For ____ No

2. What is your date of bitth (month/day/year) . . . . . . . . . . . . . . . . . . . . . ___________

3. What is your occupation? _______________________________________________

4. Highest year of education completed: _____________________________________

5. Are you currently employed? ____ Yes ____ No

a. If yes: (1) Where do you work? (name & address) _____________________

____________________________________________________

(2) When did you start work? (month/year) ____________________

b. If no: (1) When did you last work (month/year)? _______________________

(2) What were your gross monthly earnings? $_________________

6. What is the total number of minor children you are legally obligated to support? ____

*
INCOME INFORMATION
*

1. Total gross salary or wages, including commissions, bonuses, and

overtime paid during the last 12 months: . . . . . . . . . . . . . . . . . . . . $_____________

2. All other money received during the last 12 months except welfare

AFDC, SSI, spousal support from this marriage, or any child
support. (Include pensions, social security, disability, unemployment,
military basic allowance for quarters (BAQ), spousal support from a
different marriage, dividends, interest or royalty, trust income, and
annuities. Include income from a business, rental properties, and
reimbursement of job-related expenses.)

** Prepare and attach a schedule showing gross receipts less cash
expenses for each business or rental property . . . . . . . . . . . . . . . $____________

3. Add lines 1 and 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $______________

DIVIDE THE RESULT IN LINE 3 ABOVE, DIVIDE IT BY 12 TO GET A MONTHLY AVERAGE FOR THE LAST 12 MONTHS, AND INSERT IN LINE 4a BELOW

ENTER YOUR GROSS INCOME FOR LAST MONTH INTO LINE 4b BELOW


	Average monthly last 12 months	Last month
4. Gross income	4a $__________	4b $__________

5. State income tax	5a $__________	5b $__________
6. Federal Income tax	6a $__________	6b $__________
7. Social Security and Hospital Tax ("FICA" and "MEDI") or self-employment tax, or the amount used to secure retirement or disability benefits	7a $__________	7b $__________
8. Health insurance for you and any children you are required to support	8a $__________	8b $__________
9. State disability insurance	9a $__________	9b $__________
10. Mandatory union dues	10a $__________	10b $__________
11. Mandatory retirement and pension fund contributions (Do not include any deduction claimed in item 7)	11a $__________	11b $__________
12. Court-ordered child support, court ordered spousal support, and voluntarily paid child support in an amount not more than the guideline amount actually being paid for a relationship OTHER than that involved in this proceeding.	12a $__________	12b $__________
13. Necessary job-related expenses (attach explanation)	13a $__________	13b $__________
14. Hardship deduction (Line 4d from Child Support Information below)	14a $__________	14b $__________
15. Add lines 5 through 14 TOTAL MONTHLY DEDUCTIONS:	15a $__________	15b $__________
16. Subtract line 15 from line 4 NET MONTHLY DISPOSABLE INCOME:	16a $__________	16b $__________

17. AFDC, welfare, spousal support from this marriage, and child support from other relationships received each month.	17 $__________
18. Cash and check accounts	18 $__________
19. Savings, credit union, certificates of deposit, and money market accounts.	19 $__________
20. Stocks, bonds, and other liquid assets:	20 $__________
21. All other property, real or personal (attach a list with values)	21 $__________
ATTACH A COPY OF YOUR THREE MOST RECENT PAY STUBS.

* EXPENSE INFORMATION *
1. PERSONS IN YOUR HOME:
	Name	Age	Relationship	Gross Monthly Income
a. List all persons living in your home whose expenses are included below (continue on attachment)	1. _____________________	____	___________	$_________
	2. _____________________	____	___________	$_________
	3. _____________________	____	___________	$_________
	4. _____________________	____	___________	$_________
===========================================================
b. List all other persons whose expenses are not included below living in your home	1. _____________________	____	___________	$_________
	2. _____________________	____	___________	$_________
	3. _____________________	____	___________	$_________
===========================================================

2. MONTHLY EXPENSES
a. Residence payments
(1) ____ Rent or ____ Mortgage		$_________
(2) If mortgage, include:
Average principle	$_________
Average interest	$_________
Impound for real proiperty taxes	$_________
Impound for homeowner's insurance	$_________
(3) Real property taxes (if not included in item 2)		$_________
(4) Homeowner's or renter's insurance (if not included in item 2)		$_________
(5) Maintenance		$_________
b. Unreimbursed medical and dental expenses		$_________
c. Child care		$_________
d. Children's education		$_________
e. Food at home and household supplies		$_________
f. Food eating out		$_________
g. Utilities		$_________
h. Telephone		$_________
i. Laundry and cleaning		$_________
j. Clothing		$_________
k. Insurance (Life, accident, etc. Do not include auto, home, or health insurance)		$_________
l. Education (specify)		$_________
m. Entertainment		$_________
n. Transportation and auto expenses (Insurance, gas, oil, and repair)		$_________
o. Installment payments (insert total and itemize in #3 below)		$_________
p. Other (specify)		$_________
q. TOTAL EXPENSES (a-p) (do not included amounts in a(2)		$_________


3. ITEMIZATION OF INSTALLMENT PAYMENTS OR OTHER DEBTS (Attach a continuation sheet if necessary)
Creditor's Name	Payment For	Monthly Payment	Balance	Date Last Payment Made
____________________	_______________	$_________	$_________	________
____________________	_______________	$_________	$_________	________
____________________	_______________	$_________	$_________	________
____________________	_______________	$_________	$_________	________


4. ATTORNEY FEES AND COSTS OF SUIT

a. To date I have paid my attorney for fees and costs:	$_________
The source of this money was: ____________________________________
b. I owe to date the following fees and costs over the amount paid:	$_________
c. My arrangement for attorney fees and costs is:
______________________________________________________________

* CHILD SUPPORT INFORMATION (THIS SECTION MUST BE COMPLETED ONLY IF CHILD SUPPORT IS AN ISSUE *
1. Health insurance for my children ____ is ____ is not available through my employer
a. Monthly cost paid by me or on my behalf for children only (Do not include the amount paid or payable by your employer:		$_________
b. Name of carrier: _________________
c. Address of carrier: ________________

d. Policy or group policy number: ________

2. Approximate percentage of time each parent has primary physical responsibility for the children: Mother ____% Father ____%

3. The court is requested to order the following as additional child support:
____ Child care costs related to employment or to reasonably necessary education or training for employment skills. (1) Monthly amount currently paid by mother: $_______ (2) Monthly amount currently paid by father: $_______ ____ Uninsured health care costs for the children (For each cost state the purpose for which the costs was incurred and the estimated monthly, yearly, or lump sum amount paid by each parent. ________________________ ________________________ ____ Educational or other special needs of the children (for each cost state the purpose for which the cost was incurred and the estimated monthly, yearly, or lump sum amount paid by each parent. ________________________ ________________________ ____ Travel expense for visitation; (1) Monthly amount currently paid by mother: $_________ (2) Monthly amount currently paid by father $_________
4. ____ The court is requested to allow the deductions identified below, which are justifiable expenses that have caused an extreme financial hardship:
Hardship Expense	Amount paid per month	How many months will you need to make these payments
a. ____ Extraordinary health care expenses (specify and attach any supporting documents)	$_________	_________
b. ____ Uninsured catastrophic losses (specify and attach supporting documents)	$_________	_________
c. ____ Minimum basic living expenses of dependent minor children from other marriages or relationships who live with you (specify names and ages of these children)	$_________	_________

d. Total hardship deductions requested (add lines a-c)	$_________

SECTION 6
OCCUPATION

(a) The name and address of your employer and the date you were first so employed.
_________________________________________________
_________________________________________________
_________________________________________________
_________________________________________________
Date First Employed: ________________________________

(b) A brief descriptions of your work.
_________________________________________________
_________________________________________________
_________________________________________________

(c) The name and address of your superior best qualified to testify as to the nature of your employment and the manner of your performance
_________________________________________________
_________________________________________________
_________________________________________________

(d) Your rate of pay since the time you commenced this occupation and the method of determining it ( e.g., hourly, weekly, monthly, commission, etc.)
_________________________________________________
_________________________________________________
_________________________________________________

(e) Answer questions (a) through (d), inclusive, for any other employment you have had during the past 10 years.
_________________________________________________
_________________________________________________
_________________________________________________

ATTORNEY FEE AGREEMENT


_________________________________hereinafter referred to as "CLIENT," agrees to pay KINSEY LAW OFFICES, hereinafter referred to as "ATTORNEYS," the sums specified below for the following services:

Choose Level Of Service:

Initials: ___ DIVORCE FORMS ONLY ($75)
Initials: ___ ATTORNEY ASSISTED DIVORCE ($250)
Initials: ___ FULL REPRESENTATION ($300 Retainer + $225 Per Hour - $1,500 minimum fee)
DIVORCE FORMS ONLY OPTION
DIVORCE FORMS ONLY OPTION: ($225.00) Immediately upon execution of this Agreement, Client shall pay to Attorneys a NONREFUNDABLE fee in the amount specified in this Paragraph. In consideration of the payment of this fee, Attorneys shall provide the Client with ONE INITIAL PHONE CONSULTATION WITH ATTORNEYS AND shall prepare and deliver to Client the FOLLOWING DOCUMENTS ONLY:

1. COMPLETE INSTRUCTIONS FOR FILING & SERVICE OF ALL DOCUMENTS
2. SUMMONS
3. PETITION FOR DISSOLUTION OF MARRIAGE
4. CONFIDENTIAL COUNSELING STATEMENT
5. CERTIFICATE OF ASSIGNMENT
6. BLANK RESPONSE
7. BLANK CONFIDENTIAL COUNSELING STATEMENT
8. EXTRA FACE PAGE PER LOCAL RULE 7.18 (L.A. COUNTY ONLY)
9. TWO INCOME & EXPENSE DECLARATION FORMS
10. TWO SCHEDULE OF ASSETS AND DEBTS
11. REQUEST TO ENTER DEFAULT
12. APPLICATION FOR DEFAULT SETTING
13. PROPERTY DECLARATION
14. DECLARATION OF COMPLIANCE
15. JUDGMENT
16. NOTICE OF ENTRY OF JUDGMENT
17. INSTRUCTIONS FOR COURT APPEARANCE

The fee the above-described forms package DOES NOT INCLUDE the cost of FILING OR SERVING the above-described documents. This option DOES NOT INCLUDE the assistance of Attorneys in preparing the forms. Client will represent him/herself as his/her own attorney in this matter, will be responsible for payment of the filing fee and any service fee and for the proper filing and service of these documents, and shall assume the risk of improper drafting and service of the papers.
ATTORNEY ASSISTED DIVORCE OPTION

ATTORNEY ASSISTED DIVORCE OPTION: ($250.00) Immediately upon execution of this Agreement, Client shall pay to Attorneys a NONREFUNDABLE fee in the amount specified in this Paragraph. In consideration of the payment of this fee, Attorneys shall provide the Client with all of the forms listed in the "Forms Only Option" section above. In addition, Attorneys shall prepare for client the following documents only:

SUMMONS
PETITION
CONFIDENTIAL COUNSELING STATEMENT
INCOME & EXPENSE DECLARATION
PROPERTY DECLARATION

In addition, Attorneys shall provide Client with ONE HOUR of attorney time to assist Client in preparing and filing additional documents as the action progresses. Additional time shall be billed to client in advance at $225.00 per hour (with a 1 hour minimum).

EXCLUSIONS: Attorney shall not:

Provide any forms other than those described above
Provide any forms unique to local jurisdictions
Provide forms or advice in connection with any law and motion matters such as Orders To Show Cause or Modifications.
Act as the attorneys of record for Client in court or in negotiations with opposing parties or attorneys.

Client understands and agrees that he/she shall represent him/herself in all court proceedings and Attorneys shall not be required to appear at any such proceedings.

The fee for services described in this section DOES NOT INCLUDE the cost of FILING OR SERVING the above-described documents. Client will represent him/herself as his/her own attorney in this matter and will be responsible for payment of the filing fee and any service fee and for the proper filing and service of these documents.

FULL REPRESENTATION OPTION

1. INITIAL RETAINER: ($300 Retainer Plus $225 Per Hour - $1,500.00 Minimum Fee) Immediately upon execution of this Agreement, Client shall pay to Attorneys an initial retainer in the amount specified in this Paragraph. This initial retainer is a FEE FOR INITIAL CONSULTATION, ACCEPTANCE OF THE CASE OR OTHER UNDERTAKING, AND CREATION OF A NEW FILE ONLY. THE INITIAL ATTORNEY RETAINER IS NOT REFUNDABLE AND SHALL NOT BE APPLIED TO ANY HOURLY FEE.

2. HOURLY FEE FOR ATTORNEY TIME: ($225.00) In addition to the initial attorney retainer and additional flat fee specified below, Client promises to pay to Attorneys a fee of $225.00 per working hour for each and every hour spent by a licensed attorney working on the above-described matter including but not limited to phone time, investigation, research, drafting, travel and court time. MINIMUM BILLING: Said hourly fee shall be billed in increments of no less than .25 hours; i.e. Client shall be billed for .25 hours for each billable period of .25 hours OR PART THEREOF.

3. OTHER HOURLY FEES: In addition to other fees described in this Agreement, Client promises to pay to Attorneys the following sums for services rendered by office personnel other than licensed attorneys:

Paralegals: $75.00 per hour
Law Clerks: $60.00 per hour
Secretarial: $15.00 per hour
Word Processing: $15.00 per hour

4. HOURLY RATES SUBJECT TO CHANGE: The rates for hourly fees described above are the prevailing rates for services as of the date of execution of this Agreement and are subject to change on 30 days written notice. Should Client decline to pay any increased rate, Attorneys shall have the right to withdraw from representation of Client.

5. MINIMUM FEE/ADVANCE PAYMENT: Client shall pay in advance to Attorneys the minimum fee indicated below for the above-described services, exclusive of any and all costs of suit. Client understands that the said Minimum Fee is the least that Client shall pay to Attorneys for the above-described services and that the total fee to be incurred by Client may exceed the said Minimum Fee. All fees paid to Attorneys below the said Minimum Fee are NOT REFUNDABLE.

MINIMUM FEE: $1,500 INCLUDING:

INITIAL RETAINER $ 300.00
HOURLY ATTORNEY FEE $1200.00
6. COSTS PAID BY CLIENT: ($250.00 Minimum) In addition to attorney fees described above Client agrees to pay all costs which are reasonably necessary to perform the above-described service or to prosecute any court action which may be brought on behalf of Client in this matter or which are otherwise reasonably necessary in the representation of Client. Costs include but are not limited to court costs, process service fees, expenses of investigation, expenses of medical examination, computer database access, and the cost of obtaining and presenting evidence. Client shall immediately upon execution of this Agreement advance to Attorneys the sum $250.00 for costs to be placed in a trust account for the benefit of Client. All costs which are not used ARE REFUNDABLE.

7. ADVANCEMENT OF ESTIMATED TRIAL FEES & COSTS UPON NOTICE OF TRIAL (LITIGATION MATTERS ONLY): Should a court action be prosecuted by Attorneys in connection with the above-described matter(s), within ten (10) days of receipt by Attorneys of notice of a trial date, Client promises to advance to Attorneys 1) all attorney fees and costs then due and unpaid and 2) all attorney fees and costs which Attorneys estimate will be incurred by client in the preparation for and prosecution of the trial. Should Client fail to advance the fees and costs described in this Paragraph when due, Attorneys, at their option, shall be permitted to withdraw from representation of Client and Client, upon the exercise of such option by Attorneys, shall sign all documents and do all things reasonably necessary to accomplish such withdrawal.

9. AUTHORIZATION FOR WITHDRAWAL FROM TRUST ACCOUNT: Attorneys are authorized to withdraw and disburse from Client's trust account such sums as are reasonably necessary to pay costs of suit brought on behalf of Client and which are reasonably necessary to pay Attorney fees as they are incurred.

10. PAYMENT OF FEES: Client promises to pay Attorneys all sums due in full on or before the fifth day after billing. Should client fail to make any payment when due, Attorneys are authorized to withdraw from Client's trust account and pay the amount of any such payment to Attorneys without prior notice to client.
11. LATE SERVICE CHARGE: If any payment or portion thereof due under this Agreement is not received by Attorneys within ten (10) days after the due date thereof, Client agrees to pay Attorneys, in addition to the payment due, a late service charge of five percent (5%) of the amount of such payment due and unpaid.

12. DISCLAIMER OF GUARANTEE: Nothing in this Contract and nothing in Attorneys' statements to Client will be construed as a promise or guarantee about the outcome of Client's matter. Attorneys make no such promises or guarantees. Attorneys' comments about the outcome of Client's matter are expressions of opinion only.

13. ATTORNEY FEES FOR COLLECTION FROM CLIENT: In case suit or action is instituted to collect any sums due under this Agreement, Client agrees to pay such additional sum over and above the amount of Client's indebtedness to Attorneys as the court may adjudge reasonable as Attorney fees incurred in such suit or action.

14. EFFECTIVE DATE: This agreement will not take effect and Attorneys shall have no obligation to provide legal services until Client both 1) returns to Attorneys a signed copy of this agreement and, 2) makes the entire advance payment specified in Paragraph 6 herein.

EXECUTED at Seal Beach, California. _________________________ DATED: ____________ CLIENT _________________________ DATED: ____________ ATTORNEY

PAYMENT OPTIONS

CREDIT CARD - VISA, MASTERCARD, AMERICAN EXPRESS-	Bring your card to the office or; Include your credit card information below; Call us with the information.
*CHECK,* *MONEY ORDER*	Mail you check or money order with your questionare and attorney fee agreement.

CREDIT CARD INFORMATION
CARD TYPE:	__________________________________________
CARD NUMBER:	__________________________________________
EXACT NAME ON CARD:	__________________________________________
CARD NUMBER:	__________________________________________
EXPIRATION DATE:	__________________________________________
BILLING ADDRESS FOR THIS CARD:	__________________________________________ __________________________________________ __________________________________________ __________________________________________