1404 Ford Street

Llano, Texas 78643

325-245-0200

mdebault@lomd.law

Potential New Client Intake Form

Thank you for your interest in hiring The Law Office of Molly Debault PLLC (“LOMD”). This form is to collect information about potential new clients and used for internal purposes only. The information provided is confidential and will be treated accordingly. Please fill out the appropriate section below if the potential new client is an individual or a business entity.

Person Filling Out This Form

Contact information

Prefix

First name *

Middle name

Last name *

Emails

Address *

Type

Upon submission, a copy of this form will be sent to the primary email.

Add email

Addresses

Street address

Country

City

State/Region

Zip/Postal code

Address type

Add address

Phone numbers

Phone number

Type

Add phone number

How did you hear about us?

Internet

Personal Referral

Other

Why are you seeking legal assistance? Please include any specific questions you may have.

Who are the parties involved? Please list the names of any individual or business that may be opposing parties or on the other side of the transaction.

NOTE: This information is for conflict-of-interest purposes. LOMD will check that LOMD does not have a relationship with a current or previous client that prevents LOMD from representing you in this matter/case.

When does it occur—what is the timeframe or timeline?

NOTICE

THE LAW OFFICE OF MOLLY DEBAULT PLLC DOES NOT REPRESENT YOU WITH REGARD TO THE MATTER/CASE DESCRIBED ABOVE UNLESS AND UNTIL THE LAW OFFICE OF MOLLY DEBAULT PLLC AND YOU EXECUTE A WRITTEN ENGAGEMENT LETTER AND THE LAW OFFICE OF MOLLY DEBAULT PLLC RECEIVES PAYMENT OF THE ADVANCE DEPOSIT, IF ANY.

Thank you.

When you are finished, please click the "Submit" button.