Is Person Claiming Injury or Damage a minor?

Yes No

If Claim is filed on behalf of the Minor Then:

Name of Guardian or Custodial Parent -

Relationship of Guardian or Next Friend -

Gender of the Guardian - Male Female

Name of Non-Custodial Parent -

Relationship of Non Custodial Parent - Mother Father

About The Person Who is Claiming Damage Full Name: First, Middle, Last: - Gender - Male Female Date of Birth: - City and State of Birth: - Present Street Address - City, State & Zip Code - Phone Number - E-Mail - County of Residence - Please add any comments you have below:

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About The Incident Causing Injury or Damage Date of Incident: MM/DD/YEAR - Time of Day: Include A.M. or P.M. - Place of Incident Please Describe Exactly Your Complaint

Send Completed Forms To: Full Name - First, Middle, Last: Mailing address: Street address or P.O. Box: City: State or Province: Zip or Postal Code: County: Telephone: Fax: E-mail address:

CONFIRMATION AND PAYMENT INFORMATION

Payment May be by one of the following credit cards.

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Charge to My Credit Card - - Yes - No

Visa
American Express
Mastercard

Card Number - - -

Expiration Date MM YY

E-mail this form by pressing the SUBMIT button below -

OR

Complete and Sign this form and fax it to (405) 275-3627

OR

Complete and Sign this form and mail it to:

OkLegal Forms - Internet Services
McKIMMEY LAW OFFICE, P.C.
24 E. Highland
Shawnee, Oklahoma 74801

With Your Check for or your Credit Card Number.

OR

If you wish, you may e-mail the form to us and call us with your credit card number at 405-275-3564.

Credit Card Orders Usually Sent First Class Mail to Address of Plaintiff on the same day received. Orders accompanied by check are sent upon notice by bank that check has cleared.

By returning this form by e-mail, by fax or by mail, I acknowledge and agree to the following:

I hereby certify as follows:

• That I am a resident of the State of Oklahoma, and have been for more than Thirty Days months prior to this date.
  
  
• That I am a bona fide resident of the County shown to be my address herein.
  
  
• That I do not seek a Change of Name for myself of the person listed herein for any fraudulent purpose.
  
  
• That McKimmey Law Office, P.C. has not provided me any legal or tax services or advice concerning this matter.
  
  

• Signature (if sending by fax or by mail)
  
  
  __________________________________

  Type your name: -

  
  

  Please tell us how you found us on the Internet, i.e., what search terms, what search engines, links, etc.

oklegalforms@yahoo.com

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8/23/02