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 FY25 expense claimed in your request. FY25 expenses are those incurred July 1, 2024 to June 30, 2025. All requests for FY25 expenses must be received by PBRC no later than July 1, 2025.

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:

Primary or Home Address

Address 1:

Address 2:

City:

State:

ZIP Code:

Work Address (if any)

Company:

Address 1:

Address 2:

City:

State:

ZIP Code:

Website:

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

Home Phone:

Cell Phone:

Work Phone:

Primary Phone Contact:

HomeCellWork

Make Check(s) Payable To:

Mail Check(s) to:

Primary/Home AddressWork Address

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

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).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.

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

E-Bulletin

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