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Application for Legal Services

  1. Applicant's Personal Information:

  2. Sex
  3. U.S. Citizen?
  4. Disabled?
  5. Marital Status:
  6. Have you or any member of your household served in the military, including National Guard and Reserves?
  7. 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.

  8. Check the box if anyone in your household receives any of these benefits:
  9. MONTHLY Income - Before Taxes and Other Deductions for ALL Household Members

  10. Is your current level of income likely to change in the future?
  11. Is your income likely to change in the next 30 days?
  12. MONTHLY Expenses

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

  14. Vehicle #1
  15. Vehicle #2
  16. Vehicle #3
  17. Do you have more vehicles, camper, motorcycles, RV, etc?
  18. 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.

  19. Sign, if appropriate:

    I am a citizen of the United States of America.

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

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

  22. Leave This Blank:

  23. This field is not part of the form submission.