Conflict of Interest Check Form

1. Prospective Client Information

• Date of request:
• Intake performed by:
• Prospective client name/business:
• Aliases or former names:
• Primary contact person and title (if entity):
• Address:
• Phone:
• Email:

2. Matter Description

• Type of matter: [Litigation/Transactional/Regulatory/Other]
• Jurisdiction/Court (if known):
• Adverse parties/opposing counsel known to date:
• Brief summary of issues:
• Urgent deadlines:

3. Parties for Conflict Search

List all related individuals/entities (attach additional sheet if needed):
- Affiliates/subsidiaries/parent companies:
- Officers/directors/partners/members:
- Key witnesses or experts:
- Insurance carriers and claim representatives:
- Account numbers, project names, or matter identifiers:

4. Existing Relationships

• Has the firm previously represented the prospective client? ☐ Yes ☐ No ☐ Unknown
• If yes, matter name/number and responsible attorney:
• Are any attorneys/staff currently representing an adverse party? ☐ Yes ☐ No ☐ Unsure
• Are there any personal or familial relationships with involved parties? ☐ Yes ☐ No (describe):

5. Conflict Database Results

• Date search completed:
• Systems/databases searched: ☐ CRM ☐ Time & billing ☐ Document management ☐ Other: ____
• Search terms used (names, aliases, entities):
• Results summary (potential conflicts, prior matters):

6. Conflict Analysis

• Potential conflict identified? ☐ Yes ☐ No
• If yes, describe nature (direct adversity, material limitation, former client, imputed conflict, etc.):
• Attorneys involved:
• Recommended action (obtain waiver, decline representation, screen personnel, etc.):

7. Screening Measures (if applicable)

• Screened attorneys/staff:
• Date and method of screening notice:
• Access restrictions implemented (document locks, billing restrictions, workspace assignments):

8. Waiver/Consent Requirements

• Parties requiring informed consent:
• Responsible attorney to obtain waiver:
• Status of waiver (requested/received/pending):

9. Approval

• Conflicts counsel/ethics partner review date:
• Decision: ☐ Approved ☐ Approved with conditions ☐ Declined
• Notes/conditions:

10. Recordkeeping

• Matter opening number (if approved):
• File location for conflict documentation:

Certification: I certify the information above is accurate and conflict procedures have been followed.

Prepared by: ___ Date: _
Reviewed by (Conflicts Counsel/Ethics Partner): ___ Date: _