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   This information is not confidential and no attorney client relationship has been formed until you have contacted me by telephone and I agree to accept you as my client.

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*Name:
*Phone Number:
Address:

Email Address:

What you have been charged with:

What County and State is your criminal case:

List all pervious convictions or plea agreements:

Are you currently on probation for anything?

List name of any possible alleged victims (if known):

List names of any possible co-defendents (people accused of commiting crime with you)?