Civil Litigation – Breach of Contract Form Name First Middle Last PhoneEmail Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country OccupationEmployment StatusEmployedRetiredName of Business, Person or Company with whom you have a dispute:Summary of your dispute/issue:Amount of total contract for goods or services:Date contract was entered Date Format: MM slash DD slash YYYY If you have complained to the Business, Person or Company, please summarize their response.Has a lawsuit been filed?YesNoIf a lawsuit has been filed, list the names of the parties, the Court where filed, case number, opposing counsel’s name and contact information, and the amount requested.If a lawsuit was filed, were the parties served?YesNoIf any legal proceedings have been filed, please upload the following Supporting Documents or email to firstname.lastname@example.org. • Lawsuit or other court paperwork, including but not limited to garnishments. • Last account statement received • Any recent correspondence • Copy of Contract for goods or services and other paperwork received. • Repair orders or receipts • Pictures State desired result, i.e. enforce contract, invalidate contract, receive property or value of property, receive refund, repair or replacement of damaged items, pain and suffering, medical expenses, reimbursement, or other remedy.Please tell us about any circumstances that have occurred that may be relevant.Please tell us about any defenses you have to the payment on the contract, if applicable, i.e. improper service, mistaken identity, identity theft, statute of limitations, payment, amount disputed, lack of authority for plaintiff to sue, bankruptcy, unlicensed debt collector, or other excuse to contract enforcement or payment.How did you hear about the Royal Legal Group, LLC?WebsiteInternet searchHyatt Legal PlansARAG Insurance GroupBNIOtherPlease describe where you heard about the Royal Legal Group, LLC below:Disclaimer: If you are sending information and documents to the Royal Legal Group LLC to be reviewed in order to determine if the Royal Legal Group LLC can represent you, the sending of such information and/or documents does not indicate a lawyer-client relationship but merely provides the Royal Legal Group LLC with a means for assessing your case or matter. Such information may also be used to begin drafting any relevant documents necessary to handle your matter.* Yes, I Agree NameThis field is for validation purposes and should be left unchanged.