1350 Avenue of the Americas 31st Floor New York, NY 10019
dsanford@sanfordheisler.com
rkornblith@sanfordheisler.com
phone: 646-402-5650
fax: 646-402-5651
700 Pennsylvania Avenue SE Suite 300 Washington, DC 20003
vmcknight@sanfordheisler.com
phone: 202-499-5200
fax: 202-499-5199
111 Sutter Street Suite 975 San Francisco, CA 94104
fgilbert@sanfordheisler.com
phone: 415-795-2020
fax: 415-795-2021
655 West Broadway Suite 1700 San Diego, CA 92101
echapin@sanfordheisler.com
phone: 619-577-4253
fax: 619-577-4250
611 Commerce Street Suite 3100 Nashville, TN 37203
ksharp@sanfordheisler.com
phone: 615-434-7000
fax: 615-434-7020
111 S. Calvert Street Suite 1950 Baltimore, MD 21202
dmarcuse@sanfordheisler.com
phone: 410-834-7420
fax: 410-834-7425
Your responses to the questions below are confidential and privileged. Your responses will not be shared with Sanford Heisler Sharp unless the questions with an asterisk are answered.
*Name
*Personal Email Address
*Personal Phone Number
*Race
*Gender
*Your Street Address
*Your City
*Your State*Your StateAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Marianas IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaVirgin IslandsWashingtonWest VirginiaWisconsinWyoming
*Your ZIP Code
*How did you hear about us?
*Select the area(s) that best apply to your potential legal claims:Gender DiscriminationPregnancy DiscriminationAge DiscriminationRace DiscriminationLGBTQ DiscriminationReligious DiscriminationDisability DiscriminationWrongful TerminationRetaliationSexual HarassmentSexual AssaultChild Sexual AbuseTitle IXWage and Hour (i.e., Violations of State and/or Federal Labor Rights Laws)Financial Services (e.g., 401(k) Mismanagement, Annuity Fraud, Investment Fraud, and Financial Elder Abuse)Whistleblower and/or Qui Tam (e.g., Medicare or Medicaid Fraud, Procurement Fraud, GSA Pricing Fraud, Customs Fraud, and Illegal Kickbacks)Other
*Please describe:
*Are you aware of any deadlines related to your potential legal claims?SelectYesNo
*Please explain:
*Are your potential legal claims against a current or former employer?SelectYesNo
*Are your potential legal claims against anyone else?SelectYesNo
*Who else engaged in wrongdoing?
*What is your relationship to the wrongdoer(s)?
*What is the name of the organization that engaged in wrongdoing?
*How many people are employed by this organization?Select1 - 9 employees10 - 19 employees20 - 49 employees50 - 99 employees100 - 249 employees250 - 499 employees500 - 1,000 employeesOver 1,000 employees
*Do you currently work for this employer?SelectYesNo
*When did you start working for this organization?
*Where do you work for this organization?
*What is your position at this organization?
*What did you earn working for this organization last year?SelectUnder $50,000$50,000 - $69,999$70,000 - $84,999$85,000 - $99,999$100,000 - $149,999$150,000 - $199,999$200,000 - $299,999$300,000 - $499,999$500,000 - $1,000,000Over $1,000,000I prefer to disclose at a later time
Do you participate in this organization’s 401(k) or pension plan?SelectYesNo
*Are you aware of any other employees who have the same or similar potential legal claims?SelectYesNo
How many other individuals have the same or similar potential legal claims?
Are the individual(s) who have the same or similar potential legal claims interested in taking legal action against this organization?SelectYesNoI don't know
Would you be able to contact the individual(s) who have the same or similar potential legal claims?SelectYesNo
*Have you reported the wrongdoing to anyone at this organization?SelectYesNo
Who did you speak with about the wrongdoing?
What action(s), if any, have been taken since you reported the wrongdoing?
*Have you received any legal advice or legal representation regarding your potential legal claims?SelectYesNo
*Have you taken any legal action (e.g., sending a demand letter or filing a lawsuit) against this organization and any other wrongdoers in connection with your potential legal claims?SelectYesNo
*Have you signed any agreement (e.g., arbitration agreement or settlement agreement) related to your potential legal claims?SelectYesNo
*What was your position at this organization?
*What did you earn in your last year working for this organization?SelectUnder $50,000$50,000 - $69,999$70,000 - $84,999$85,000 - $99,999$100,000 - $149,999$150,000 - $199,999$200,000 - $299,999$300,000 - $499,999$500,000 - $1,000,000Over $1,000,000I prefer to disclose at a later time
Did you participate in this organization’s 401(k) or pension plan?SelectYesNo
*When did your employment start and end at this organization?
*Since your employment ended at this organization, have you worked for any other organizations?SelectYesNo
Where have you worked?
Has your expected annual income decreased?SelectYesNo
How much less do you expect to earn this next year?
*Did you report the wrongdoing to anyone at this organization?SelectYesNo
Are the individual(s) who have the same or similar potential legal claims interested in taking legal action against your former employer?SelectYesNoI don't know
*Have you taken any legal action (e.g., sending a demand letter or filing a lawsuit) against your former employer and any wrongdoer in connection with your potential legal claims?SelectYesNo
*Who are your potential legal claims being brought against?
*Are you aware of any other people who have the same or similar potential legal claims?SelectYesNo
Are the individual(s) who have the same or similar potential legal claims interested in taking legal action against the wrongdoer(s)?SelectYesNoI don't know
*Have you taken any legal action (e.g., sending a demand letter or filing a lawsuit) against the wrongdoer(s) in connection with your potential legal claims?SelectYesNo
*If we have any follow-up questions, what day(s) and time(s) this next week are you available to discuss your potential legal claims?
If you would like to relate any additional information about your potential legal claims, please share this information in the space below.
