Please enable JavaScript in your browser to complete this form.PLAINTIFF Name: *FirstLastDEFENDANT Name: *FirstLastSpelled in Hebrew:Spelled in Hebrew: Street Address *Street Address: *City/State/ZIP *City/State/ZIP: *Primary Phone #: *Primary Phone #: *Secondary Phone #:Secondary Phone #: Email: *Email: *Will be retaining a To'en: *YesNoUndecidedWill be retaining a To'en: *YesNoUndecidedName of To'en: Name of To'en:Additional Party/Company Name:When ApplicableAdditional Party/Company Name: When ApplicableStreet Address:Street Address:City/State/ZIP:City/State/ZIP:Home Phone #:Home Phone #: Work Phone #:Work Phone #: Cell Phone #:Cell Phone #: Email:Email: CLAIM AMOUNT:NATURE OF CLAIM:Payment Authorization:Name on CC:Security Code:Expiration Date:By checking the box below, I hereby authorize all charges that are incurred through the Hazmana process, mediation process or any related activities. *Choice 1Please contact the Bais Din Secretary to discuss rates for claims under $5,000. Submission of application does not imply a commitment to a specific course of action on the part of the Bais HaVaad. The Bais HaVaad reserves the right to determine what action (if any) will be taken. Payment will not be processed until time of service.MessageSubmit