(a) The Committee shall prepare and approve a form of claim for reimbursement.
(b) The form shall include at least the following information provided by the claimant under penalty of perjury:
(b)(1) the claimant's name and address, home and business telephone, occupation and employer, and social security number for purposes of subrogation and tax reporting;
(b)(2) the name, address and telephone number of the lawyer or licensed paralegal practitioner who has dishonestly taken the claimant's money or property;
(b)(3) the legal or other fiduciary services the lawyer or licensed paralegal practitioner was to perform for the client;
(b)(4) how much was paid to the lawyer or licensed paralegal practitioner;
(b)(5) the copy of any written agreement pertaining to the claim;
(b)(6) the form of the claimant's loss involved (e.g. money, securities or other property) and the attachment of any documents that evidence the claimed loss such as cancelled checks, title instruments, deeds or stock certificates;
(b)(7) the amount of loss and the date when the loss occurred;
(b)(8) the date when the claimant discovered the loss and how the claimant discovered the loss;
(b)(9) the lawyer's or licensed paralegal practitioner’s dishonest conduct and the names and addresses of any persons who have knowledge of the loss;
(b)(10) identification of whom the loss has been reported to (e.g. county attorney, police, disciplinary agency, or other person or entity), and a copy of any complaint and description of any action that was taken;
(b)(11) the source, if any, from which the loss could be reimbursed, including any insurance, fidelity or surety agreement;
(b)(12) the description of any steps taken to recover the loss directly from the lawyer, licensed paralegal practitioner or any other source;
(b)(13) the circumstances under which the claimant has been, or will be, reimbursed for any part of the claim (including the amount received or to be received, and the source), along with a statement that the claimant agrees to notify the Committee of any reimbursements the claimant receives during the pendency of the claim;
(b)(14) the existence of facts believed to be important to the Committee's consideration of the claim;
(b)(15) the manner in which the claimant learned about the Fund;
(b)(16) the name, address and telephone number of the claimant's present lawyer or licensed paralegal practitioner, if any;
(b)(17) the claimant's agreement to cooperate with the Committee in reference to the claim, as required by the Utah or Federal Rules of Civil Procedure, in reference to civil actions which may be brought in the name of the Bar, pursuant to a subrogation and assignment clause, which shall also be contained within the claim;
(b)(18) the name and address of any other state fund to which the claimant has applied or intends to apply for reimbursement, together with a copy of the application; and
(b)(19) the statement that the claimant agrees to the publication of appropriate information about the nature of the claim and the amount of reimbursement, if reimbursement is made.
(c) The claimant shall have the responsibility to complete the claim form and provide satisfactory evidence of a reimbursable loss.
(d) The claim shall be filed with the Committee by providing the same to the Utah State Bar, Fund for Client Protection at the Law and Justice Center, 645 South 200 East, Salt Lake City, Utah 84111.
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