Attorney Name:*
Office Phone:*
Mobile Phone:*
Email Address:*
State of Bar License:*
Bar License Number:*
HNBA Member?*

Client/Case Information

Type of Legal Matter:*
Case Number:*
Client Name:*
Client Address:*
Client Phone:*
Client Email Address:*
Client Country of Origin:*
Client Age:*
Description of Immigration Legal Services:*

By clicking on the box below, the undersigned attorney confirms and certifies as follows:

i. She/he is a licensed attorney currently in good standing in the State of Bar License listed in this application,       with no disciplinary action pending against him/her;

ii. She/he carries a policy of professional liability insurance with   minimum coverage of $100,000;

iii. She/he has informed the client that the fee (or portion thereof) for the representation is being paid by a third party and that the client has given informed consent, and that said third party payment will in no way interfere with the lawyer’s independence of professional judgment or with the client-lawyer relationship;

iv. She/he authorizes the HNBA to contact the client in regards to the grant application; and

v. She/he is charging an hourly rate up to $100.

Check Box*

Upload: Retainer Agreement and one of the following documents (depending on case type):

  1. Immigration Judge Order indicating no bond pursuant to INA § 236(c) or I-286 indicating “detained in custody of Department of Homeland Security”;
  2. Case Status Summary from Office of Refugee Resettlement - Only cases that are marked Code 4 are eligible for a grant.
  3. Form I-830 that is notated “CR” in the top right hand corner where bond was granted pursuant to Rodriguez v. Robbins.
Retainer Agreement*
One of the above documents:*

*DISCLAIMER: In evaluating grant applications, the Hispanic National Bar Association is relying on the applicant lawyer’s statements with respect to licensure, good standing to practice law, competence to undertake a given representation, exercise of independent judgment, and other matters related to the purpose of this grant, but it has not independently verified the truth or accuracy of such statements. A grant award by the Hispanic National Bar Association is not and should not be construed to mean an endorsement of the lawyer receiving the award, or as vouching for the lawyer’s competence or experience to handle the matter for which the grant is requested.