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2. Court Case Number:
4. Applicant's Name:
5. Previous Name/Maiden Name

7. Applicant's Personal Information:

9. Address
11. City
12. State
13. Zip Code
15. Email Address
16. County
18. Phone Number
20. Age
21. Date of Birth
22. Race
24. Sex

    1. Female
    2. Male
25. U.S. Citizen?

    1. Yes
    2. No
26. Disabled?

    1. Yes
    2. No
28. Language
29. Marital Status:

    1. Married
    2. Divorced
    3. Separated
    4. Never Married
    5. Common Law
    6. Widowed
31. Have you or any member of your household served in the military, including National Guard and Reserves?

    1. You
    2. Other
33. Number of people under age 18 in your household:
34. Number of other adults living in your household:
36. Total number of people in your household:
38. Who is your legal problem against? (Name)
40. How do you know this person?

42. In order to consider your application for the widest range of programs available, it's important for us to get complete information about your household income and the things you own.

44. Check the box if anyone in your household receives any of these benefits:

    1. SSI
    2. TANF
    3. SNAP (Food Stamps)
46. Amount of benefits received:

48. MONTHLY Income - Before Taxes and Other Deductions for ALL Household Members

50. Wages (Yours)
52. Other Wages (Name of person)
53. (Amount of wages)
55. Other Wages (Name of person)
56. (Amount of wages)
58. Social Security
59. Child Support
60. Unemployment
62. Pension
63. Other
65. Is your current level of income likely to change in the future?

    1. Yes
    2. No
66. Is your income likely to change in the next 30 days?

    1. Yes
    2. No
    3. Increase
    4. Decrease
    5. No Change

68. MONTHLY Expenses

70. Mortgage or Rent
71. Current Taxes
72. Child Support Paid
74. Health Insurance
75. Daycare

77. Transportation - Anything with a motor that you own.

79. Vehicle #1

    1. Work
    2. Other Household Needs
    3. Other Use
80. Vehicle #2

    1. Work
    2. Other Household Needs
    3. Other use
81. Vehicle #3

    1. Work
    2. Other Household Needs
    3. Other Use
83. Do you have more vehicles, camper, motorcycles, RV, etc?

    1. Yes
    2. No
85. Total value of cash you have, money in the bank, CD's, stocks, investments, retirement accounts that weren't created during employment.
87. Consider the value of everything else you own - furniture, household furnishings, jewelry, tools, home or land you don't live in. If you had to have a garage sale type sale of these things, how much would you expect to get for them all together?
89. Electronic Signature Agreement

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.

91. Sign, if appropriate:

    I am a citizen of the United States of America.

93. Electronic Signature
94. Date:
    Date:

96. Please be advised that this form is NOT AN AGREEMENT FOR REPRESENTATION - it is an APPLICATION ONLY.

98. This is only the beginning of the application process.  You should anticipate additional questions being asked.

Leave This Blank:


100. 1. Receive an email copy of this form.
101. Email address

     This field is not part of the form submission.

102. Submit

* indicates a required field