Legal Assistance Request Form

    I hereby request that an Attorney for the Palm Beach County PBA investigate the following incident and provide the legal assistance necessary to obtain the relief sought.

    Personal Information
    Agency Information
    I am seeking representation from the Palm Beach County Police Benevolent Association, Inc. for either a Departmental Investigation, Grievance or a Will.

    PLEASE BE ADVISED, that pursuant to Palm Beach County PBA Legal Assistance Policies, only eligible members are entitled to legal assistance by PBA Attorneys.

    If, at any time, it is determined that an applicant for legal assistance is not a PBA member in good standing, legal assistance by the PBA Attorney will be terminated.

    I acknowledge receipt of this admonition and understand it. I further acknowledge receipt of the Palm Beach County PBA Legal Assistance Policies 6-1 and Florida PBA Policy IV(E) - LEGAL DEFENSE BENEFIT, copies of which can be found here, and agree to work cooperatively with my PBA Attorney or attorney in the handling of this matter.

    I have not retained any other attorneys regarding this matter. If I should at any time obtain private counsel in this matter I agree to immediately notify the PBA. I also understand that the PBA will withdraw from this matter and have no further responsibilities to represent me in his case.

    By selecting the "Submit" button, you are signing this Agreement electronically. You agree your electronic signature is the legal equivalent of your manual and/or handwritten signature on this Agreement. By selecting "Submit" using any device, means or action, you consent to the legally binding terms and conditions of this Agreement. You further agree that your signature on this document (hereafter referred to as your "E-Signature") is as valid as if you signed the document in writing. By selecting "Submit", you acknowledge receipt of these disclosures statement and agree to work cooperatively with my PBA Attorney in the handling of this matter. *