Hazmanah Application - The Bais HaVaad Halacha Center

PLAINTIFF Name: *

First

Last

DEFENDANT Name: *

First

Last

Spelled in Hebrew:

Street Address *

Street Address: *

City/State/ZIP *

City/State/ZIP: *

Primary Phone #: *

Secondary Phone #:

Email: *

Will be retaining a To'en: *

Yes
No
Undecided

Will be retaining a To'en: *

Yes
No
Undecided

Name of To'en:

Additional Party/Company Name:

When Applicable

Additional Party/Company Name:

When Applicable

Street Address:

City/State/ZIP:

Home Phone #:

Work Phone #:

Cell Phone #:

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 1

Please 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.