Client Intake Questionnaire

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Personal Information Name

Address

City

State ZIP

Home Telephone Number

Mobile Telephone Number

Work Telephone Number

Contact Preferences

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Check all that apply.

Home Mobile Work

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E-mail Address

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May we contact you by email?

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Are you currently employed?

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If so, where?

FALSE CLAIMS ACT - the False Claims Act and similar statutes generally allow a person to bring a lawsuit on behalf of the government whom they believe has been defrauded by the defendant. If you believe that you may have a case under the False Claims Act, or a whistleblower statute, please provide the following information: (If you case involves Excessive Force, or you are charged with a crime please go to question #x).

How Can We Help You? Company that you believe is involved in committing fraud:

Location of Company:

Describe the general nature of the action which you believe caused false claims to be submitted to a government:

Do you have any documents that support your allegations?

Yes No

Do you have any document that show that the defendant submitted a false claim to the government?

Yes No
If there are documents that would support your claim, where are those documents located?

Have other attorneys worked on this matter?

Yes No
Who engaged in or directed this fraud

When did you first learn of the fraud

When did the fraud begin

When did the fraud end

Have you reported you allegations/concerns to anyone including the company, government, law enforcement, or the media?

Yes No

Do you still work for this company?

If you no longer work for this company were you fired? If so, explain.

Did you file a wrongful termination case or claim? If so, provide the case name, number, Court in which the case was filed and the case status.

Have you ever filed any lawsuit before? If so, what was the nature of the case?

How much money do you believe was paid by the government because of the fraud? Please explain and include a time period.

The use of the Internet or this form for communication with the firm or any individual member of the firm does not establish an attorney-client relationship. Confidential or time-sensitive information should not be sent through this form.

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Contact Information Name

E-mail Address Please enter a valid e-mail address.

Phone Please enter a valid phone number. You may use 0-9, spaces and the ( ) - + characters.

Brief description of your legal issue

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Michael C. Rosenblat, P.C
707 Skokie Boulevard, Suite 600
Northbrook, IL, 60062
Office: 847-480-2390
Toll Free: 888-833-1428
Mobile: 847-494-2390
Fax: 847-562-5051
Northbrook Law Office Map| Email Us

Michael C. Rosenblat, P.C, serves the Chicago, Illinois area including Evergreen Park, Burbank, Oak Lawn, Hickory Hill, Palos Hills, Lemont, Bolingbrook, Naperville, La Grange, Wheaton, Elmhurst, Lombard, Elk Grove, Des Plaines, Niles, Morton Grove, Skokie, Glenview, Northbrook, Arlington Heights, Schaumburg, Elgin, Cook County, Lake County, McHenry County, DuPage County, Kane County, Kendall County, Grundy County, Will County and Kankakee County.