Litigation Fund Request Form

The Litigation Fund is available ONLY to Judicare and pro bono attorneys handling cases through MLSC-funded agencies. Please complete all required information below and attach supporting documentation for EACH FY27 expense claimed in your request. FY27 expenses are those incurred July 1, 2026 to June 30, 2027. All requests for FY27 expenses must be received by PBRC no later than July 1, 2027.

Tell us about yourself! Please type full names and addresses as you'd like communications to be addressed.

Prefix:

First Name:

Last Name:

Email Address:

Phone Contact (s) (XXX-XXX-XXXX)

Home Phone:

Cell Phone:

Work Phone:

Primary Phone Contact:

HomeCellWork

Make Check(s) Payable To:

Address

Address 1:

Address 2:

City:

State:

ZIP Code:

CASE & EXPENSES INFORMATION

Please include all expenses related to this case. To add another case's expenses, click the link under the bottom-right side of this double-lined box.

Case Type:

Pro BonoJudicareReduced Fee

Agency Sponsoring Case:

Agency Case Number:

Court Case Number

Please affirm that this is an MLSC-eligible case

I affirm

Client Name:

Will you be submitting mileage and/or other expenses? Check all that apply.

Mileage ExpensesOther Expenses

MILEAGE EXPENSES

Date:

Origination Full Address

Destination Full Address

Purpose:

Total Miles:

Requested Amount (Miles x.$50):

EXPENSES OTHER THAN MILEAGE

Date:

Type of Expense (e.g. postage, discovery, etc.)

Description:

Amount:

TOTAL CASE EXPENSES

Miles + Other Expenses:

Request Type:

Preapproval only: PBRC will review and hold requested amount for pre-approved expense(s). After submission, PBRC will review your request and communicate the status of your pre-approval. Once pre-approved, please submit documentation of payment to have your reimbursement processed. Reimbursement: PBRC will issue you payment for expenses you have previously covered.Direct Pay: PBRC will issue a check payable to the listed vendor and mail you the check, which you can then provide to the vendor. Please contact Liz Twigg at ltwigg@probononmd.org for direct payments.

Attach Supporting Documentation for ALL Claimed Expenses (receipts, invoices, billings, GoogleMaps or MapQuest instructions for mileage, etc.)

If this is a hardship request per PBRC's new policy, check the box below.

Check here

TOTAL REIMBURSEMENT AMOUNT REQUESTED:

Type your name to sign:

Today's Date

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