WISCONSIN JUDICARE, INC.
AUTHORIZATION AND CERTIFICATION FORM

	This form must be signed in two places on the lines below and returned to Wisconsin Judicare, Inc. if the client does not have a current Judicare card. No payment of attorney’s fees will be made unless this form has been received by Judicare. This form may be sent to Judicare by the client or by the attorney.

1. I certify that the information supplied to Wisconsin Judicare to obtain Judicare services is true and accurate to the best of my knowledge.

2. I understand and agree to the following:

   Federal law now requires Wisconsin Judicare, Inc. to give federal officials that are auditing or monitoring Wisconsin Judicare, Inc.’s activities the following information: your name and records containing your eligibility for services by Wisconsin Judicare. In addition, if legal assistance is provided to you beyond brief service and counsel and advice, Wisconsin Judicare, Inc. may be required to provide to federal officials that are auditing or monitoring Wisconsin Judicare, Inc., a written statement of facts signed by you upon which a lawsuit filed by you would be based, your retainer agreement with Wisconsin Judicare and records concerning any client trust funds, if applicable. As required by law, Wisconsin Judicare, Inc. may disclose this limited information above to the federal officials that audit or monitor the activities of Wisconsin Judicare, Inc. and any independent auditor or monitor receiving federal funds to conduct such auditing or monitoring.

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   Applicant’s Signature	Date

3. I hereby swear that I am a United States citizen.

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   Applicant's Signature	Date