EASH LAW PC

114 South Main Street
Middlebury, IN 46540

(574) 825-9665

Please fill out the information below to the best of your ability. Leave blank any areas that you are not sure on how to answer. Thank you!

Contact information: Your Information

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First name *

Middle name

Last name *

Date of birth

Company

Emails

Email Address *

Type

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Addresses

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Phone numbers

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Spouse Name (if you are married)

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Spouse's Date of Birth

Opposing Party Information

Please fill out as much information on the opposing party as you can.

Name(s) of Opposing Party(s)

Address for Opposing Party

Phone Number of Opposing Party

Email Address Opposing Party

Injury or Wrong Committed

This section will cover the injury or wrong you believe you have suffered. Fill out as much information as possible.

What was the date this injury took place?

What type of litigation do you anticipate filing in this cause?

Personal InjuryMedical MalpracticeProperty DisputeBreach of Contract LitigationTortious Interference with a business relationshipNegligenceIntentional Infliction of Emotional DistressInvasion of PrivacyTrespassingAssault / BatteryDefamationNegligent Infliction of Emotional DistressProduct Liability ClaimHOA Violations Against HomeownersCivil Rights ViolationsViolations by Law EnforcementOther (please describe below)

Do you have any supporting documentation you would like to provide to our office? If so, please upload here.

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Please prepare a summary of your case including dates, times, contact between parties, what was said, etc. (We must write a summary of what has taken place when we draft the complaint and this helps us do so along with saving time of hours you may be billed for this case. Thank you. This may be done in Microsoft Word and uploaded at the link below. )

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