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Equal Justice Solutions | High-Stakes Public Interest Law Firm

CLIENT FINANCIAL DISCLOSURE FORM

Equal Justice Solutions, PBC
Public Interest Law Firm

Financial Information

(Provide figures for the last three fiscal years.)

1. Annual Revenue:

2. Gross Profit:

3. Net Profit:

Outstanding Liabilities:

List all lines of credit available to the business:

Beneficial Ownership Information

(A “Beneficial Owner” is any individual or entity who, directly or indirectly, owns 15% or more of the company or has significant control over business decisions.)

List of Beneficial Owners (Individuals or Entities):

Name

Ownership %

Accredited Investor? (Yes/No) :

Entity Instead of Natural Person? (Yes/No):

1

2

3

  • If any Beneficial Owner is an entity, a separate form must be completed for that entity.

  • If any Beneficial Owner is an Accredited Investor, explain how they qualify under SEC rules (e.g., net worth exceeding $1 million excluding primary residence, annual income of $200,000 individually or $300,000 jointly).

  • Income for the Last Three Years of Any Owner Holding 15% or More Equity in the Business:

Owner Name

Year 1

Year 2

Year 3

1

2

3

  1. Alignment with Christian Values of Service & Free Enterprise
    • Explain how your business aligns with our Christian mission of service and using free enterprise to benefit humanity (use additional sheets as needed):.
  1. Extenuating Circumstances
    • Explain any unique financial or operational hardships that should be considered in the application process (use additional sheets as needed):

Certification & Penalties for False Statements

“A false balance is an abomination to the Lord, but a just weight is His delight.” – Proverbs 11:1

By signing below, I certify under penalty of perjury under the laws of the United States that the information provided in this application is true, correct, and complete to the best of my knowledge. I understand that any misrepresentation, omission, or fraudulent statement in this application will result in the following penalties:

  • 1. Immediate disqualification from the program.
  • 2. Liability for the full cost of services rendered at a rate of $695 per hour, plus interest.
  • 3. Liability for attorneys' fees and costs incurred in recovering false or misrepresented funds.

I acknowledge that the organization relies on this information to determine eligibility, and any falsehood or concealment of material facts constitutes fraud.