Wyo. Client Prot. Fund R. 4

(a) The Committee shall prepare and approve a form for claiming reimbursement.

(b) The form shall include at least the following information provided by the claimant

under penalty of perjury:

(1) The name and address of Claimant; home and business telephone; occupation and employer; and social security number;

(2) The name, address and telephone number of the lawyer alleged to have

dishonestly taken the Claimant’s money or property, and any family or business

relationship of Claimant to the lawyer;

(3) The legal services the lawyer was to perform for Claimant;

(4) The amount paid to the lawyer;

(5) A copy of any written agreement pertaining to the claim;

(6) Copies of checks, money orders, receipts, or other proofs of payment;

(7) The form of Claimant’s loss (e.g., money, securities or other property);

(8) The amount of loss and the date when the loss occurred;

(9) The date when Claimant discovered the loss was the result of dishonest

conduct by the lawyer, and how Claimant discovered the loss;

(10) The lawyer’s dishonest conduct and the names and addresses of persons

who have knowledge of the loss;

(11) The name of the person(s), if any, to whom the loss has been reported (e.g.,

law enforcement, the Office of Bar Counsel, or other person or entity) and a copy of

any complaint and description of any action that was taken;

(12) The source, if any, from which the loss can be reimbursed including any

insurance, fidelity or surety agreement;

(13) The description of any steps taken to recover the loss directly from the

lawyer, or any other source;

(14) The circumstances under which 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 Claimant agrees to notify the Committee of

any reimbursements Claimant receives during the pendency of the claim;

(15) The existence of facts believed to be important to the Committee’s consideration of the claim;

(16) The name, address and telephone number of Claimant’s present lawyer;

(17) Claimant’s agreement to cooperate with the Committee in reference to the

claim or as required by Rule 10, in reference to civil actions which may be brought

in the name of the Committee pursuant to a subrogation and assignment clause

which shall also be contained within the claim;

(18) Claimant’s agreement to repay the Fund if Claimant is subsequently

reimbursed from another source;

(19) The name and address of any other jurisdiction’s fund to which Claimant

has applied or intends to apply for reimbursement, together with a copy of the

application; and

(20) A statement that Claimant agrees to the publication of appropriate information about the nature of the claim and the amount of reimbursement if

reimbursement is made.

(c) Claimant shall have the responsibility to complete the claim form and provide

satisfactory evidence of a reimbursable loss.

(d) The claim shall be signed by Claimant under penalty of perjury and shall be filed

with the Wyoming State Bar, 4124 Laramie St., P.O. Box 109, Cheyenne, Wyoming

82003.