<p>APPLICATION FOR MODERATE MEANS PROGRAM MEMBERSHIP</p><p>PACE WOMEN’S JUSTICE CENTER 78 NORTH BROADWAY WHITE PLAINS, NY 10603 914-422-4069</p><p>Applicant: Please complete the following information, attach a business card, a resume if available, separate sheets if necessary and a copy of the Declarations page of your malpractice insurance policy and return to the Pace Women’s Justice Center at the above address, Attention: Moderate Means Panel</p><p>1. General Information:</p><p>Name: ______# of lawyers in firm: ______</p><p>Firm Name: ______</p><p>Office address: ______</p><p>E-mail address: ______</p><p>Office phone: ______Fax #: ______</p><p>2. Education (List each college, law school and post graduate school attended, years attended, degree received and years degrees received):</p><p>College: ______</p><p>Post Graduate: ______</p><p>Law School: ______</p><p>Post Graduate Law: ______</p><p>Specialized Training: 3. Date admitted in New York: ______Department: ______</p><p>4. Engaged in active practice since: ______</p><p>5. Admitted to practice before other tribunals and jurisdictions (federal courts, administrative agencies, etc.) and dates of admissions:</p><p>6. Detail your employment history since date of admission (Attach a separate sheet or resume if necessary):</p><p>7. List categories of matters in which you concentrated your practice during the past five years (Give the approximate percentage of your practice devoted to each category during each year):</p><p>______% ______</p><p>______% ______</p><p>______% ______</p><p>______% ______</p><p>8. State the average number of trials per year you handled during the past five years: ______</p><p>State the number in Family Court: ______</p><p>State the number in the Supreme Court Matrimonial Part: ______</p><p>9. Have you ever been admonished or disciplined for professional misconduct or wrongdoing? ______Yes _____ No</p><p>If your answer is “Yes”, please explain on a separate sheet and attach to this Application. 10. Has a client ever had a guilty verdict entered against you? _____ Yes _____ No</p><p>If you answer to this question is “Yes”, please explain on a separate sheet and attach to this Application.</p><p>11. List foreign languages you are proficient in (indicate whether you understand, read, speak fluently or write):</p><p>12. List any law review articles or other pertinent publications which you have written, and any pertinent lectures you have given:</p><p>13. State whether you currently have a policy of professional liability insurance covering your practice:</p><p>_____ Yes _____ No</p><p>If your answer is “Yes”, attach the Declarations page of your insurance policy to this Application. If your answer is No, you must have insurance before you are accepted on the Panel.</p><p>14. List any Bar Association Memberships: CERTIFICATION FOR MEMBERSHIP WITH THE MODERATE MEANS PANEL AND</p><p>AUTHORIZATION TO DISCLOSE INFORMATION</p><p>I HEREBY CERTIFY THAT:</p><p>I AM A MEMBER IN GOOD STANDING OF THE BAR OF THE STATE OF NEW YORK. I ACTIVELY PRACTICE LAW AT THE OFFICE ADDRESS SET FORTH ABOVE.</p><p>THE STATEMENTS AND OTHER INFORMATION IN THIS APPLICATION ARE TRUE AND COMPLETE. I AGREE TO NOTIFY THE PACE WOMEN’S JUSTICE CENTER PROMPTLY IN WRITING IF ANYTHING OCCURS WHILE I AM A MEMBER OF ANY OF THE PANEL WHICH MAKES ANY SUCH STTEMENT OR INFORMATION UNTRUE OR INACCURATE. WITHOUT LIMITING THE FOREGOING, I AGREE TO NOTIFY THE CENTER IN WRITING IF MY PROFESSIONAL LIABILITY INSURANCE IS TERMINATED OR DECREASED OR IF I AM INVESTIGATED, REPRIMANDED OR DISCIPLINED CONCERNING AN ALLEGATION OF PREFESSIONAL MISCONDUCT, OR IF I AM A DEFENDANT IN A LAWSUIT FILED BY A CLIENT OR PRIOR CLIENT OF MINE.</p><p>I CONSENT THAT INFORMAITON ABOUT ME IN THIS APPLICATION OR OTHERWISE KNOWN TO THE CENTER MAY BE FURNISHED TO CLIENTS SEEKING REFERRAL TO THE PANEL.</p><p>I UNDERSTAND THAT MY MEMBERSHIP ON THE PANEL IS AT THE DISCRETION OF THE CENTER AND THAT I CAN BE REMOVED, WITH OR WITHOUT CAUSE, AT ANY TIME.</p><p>DATED: </p><p>SIGNATURE: </p><p>PRINT NAME: </p><p>STATE OF NEW YORK ) SS. COUNTY OF )</p><p>ON THIS ___DAY OF ______, 200_, BEFORE ME CAME ______, TO ME KNOWN TO BE THE PERSON DESCRIBED IN THE FOREGOING INSTRUMENT, AND ACKNOWLEDGED THAT HE/SHE EXECUTED THE SAME. </p><p>NOTARY PUBLIC Pace Women’s Justice Center In conjunction with The Westchester Women’s Bar Association Present the</p><p>Moderate Means Panel</p><p>The Moderate Means Panel is designed to find attorneys for individuals with have moderate income levels who have some money to hire an attorney but cannot afford prevailing attorney rates. The attorneys who participate in this program are paid reduced retainer amounts (no more than $2,000) upon being hired and monthly payments toward legal fees, which will be billed at a suggested hourly rate of $100.00 for all legal work done on behalf of the clients. </p><p>A common misunderstanding is that clients accepted into the Moderate Means Panel obtain free legal assistance. This is not true. PWJC staff tell prospective clients that they must have the funds to pay the retainer fee before a moderate means attorney will be contacted. Prospective clients are asked to complete an Application on which the fee structure is clearly stated. The Application clearly states that inaccurate financial information provided by the client may result in either an adjustment of the retainer and hourly rate or termination of the attorney’s services. Furthermore, completing the Application does not guarantee that a prospective client will be referred to an attorney. </p><p>PWJC staff review all applications for substantive difficulty and the client’s ability to pay. Upon the client’s acceptance to the program and the moderate means panel attorney, the client’s Application and a letter confirming the engagement are sent to the attorney and client. </p><p>Upon payment of the retainer fee engaging the attorney, an attorney-client relationship exists between the client and the Moderate Means Panel attorney. The PWJC is no longer involved in the matter and will not be a party to any dispute or arbitration regarding the matter.</p><p>How the program works:</p><p>1. The potential client calls the Pace Women’s Justice Center (PWJC) and expresses the desire to find an affordable attorney to represent them in a family law matter. 2. The PWJC attorney proves an Application to the potential client. 3. Upon receipt and review of the Application with the potential client, the PWJC attorney will inform the potential client if they qualify for the program. 4. The PWJC will then contact Moderate Means Panel attorneys to determine interest and availability. 5. Once an attorney expresses an interest in working with the client, the client is given the attorney’s contact information. It is the client’s responsibility to contact the attorney. 6. Letters of confirmation, stating the attorney’s contact information, the fee structure, and reminding the client that the fees are based upon the information contained in their Application, are then sent to both the attorney and the client. 7. Thereafter, the PWJC is no longer involved in the matter.</p><p>For further information about becoming a Panel Attorney, please contact:</p><p>The Pace Women’s Justice Center 78 North Broadway White Plains, NY 10603 914-422-4069 Attn.: Moderate Means Panel</p>