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3554 Chain Bridge Road
Suite 402
Fairfax, Virginia 22030

(703) 865-7480 phone
(703) 434-3510 fax

POTENTIAL CLIENT INFORMATION

Please read the instructions to this form carefully.

It is very important for you to realize that, unless you have signed a retainer agreement with the firm of Cook & Kitts, PLLC, we do not represent you and the fact that you are submitting the information on questionnaire does not mean that we are your attorneys. Even if you do not retain us, however, any communication you make to this firm for the purposes of obtaining legal advice is privileged and confidential.

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Your Full Name
Email (non-work)
Phone
Address
City, State, Zip
Employer (all aliases)

Parties and Companies of Interest Please make a ?cast of characters,? including all of the people relevant to your case, along with a brief synopsis of their role in your case. Identify people by their full names whenever possible, and include their job titles if you know them. If more than one company is involved, identify each employer.	Employment Summary Start from the beginning when you were first hired, and provide a history of the most important events in your employment. Include your job title, the name of your supervisor, and the name of the person that hired you. Include whether you worked in Virginia, D.C., or Maryland, or some other state.

Evaluation History Please describe any written or performance reviews you may have had. Include any other ways that your employer evaluated how well you were doing your job (for example achieving sales goals, letters of criticism or congratulations, etc.) Include any raises or bonuses that you received.	Pay Conditions Please describe how you were paid. Were you paid for each hour of work (i.e., your paychecks varied depending on the amount of hours you worked) or were you paid salary (i.e., you always received the same amount of pay on every check, regardless of how many hours you worked)? If you were paid salary and worked less than 40 hours, was any amount deducted from your check?

Incidents of Dispute Include any incidents where you believed you were treated unfairly or differently for any reason.	Damages Describe fully your damages, including but not limited to the following: loss of income; loss of benefits (health, life, dental, eye care, pension, profit sharing); any expenses you have incurred that you would not have, had you continued to be employed; the value of any stock options or other similar items.

Government Clients Did your employer contract with the federal government or with any state or local government? Did your employer otherwise do business with or receive money from the federal, state, or local government? If so,	Legal/Ethical Violations Did your employer (or co-worker or manager) engage in any fraudulent, illegal or unethical actions? If so, please describe. Include in your answer any steps you took to stop your employer?s illegal actions.

Attach Documents Please attach copies of any documents you would like us to review and consider.

POTENTIAL CLIENT INFORMATION

Cook & Kitts is a specialized boutique law firm based in Northern Virginia and serving the D.C. metropolitan area