*1. Client's full name:  

2. Name of person completing form, if other than client:

3. Date of birth: (mm/dd/yy) (for verification and statistical purposes only)

*4. Address: (information will be sent to this address)          

*City:

*State:

5.     *Zip:

*6. Phone:  (cell, land line, and/or work numbers)

*7. Email:        _

*9. Have you applied for legal aid with the appropriate legal aid provider? Was that approved? Was that denied?

*10. How many people reside in your household?

# of adults: One Two Three Four Five Six or More

# of children: One Two Three Four Five Six or More

Earned Income

11. Wages: Income from ALL wage earners in your household, regardless of their involvement in your case

Hourly wage ($/hr)             Average hours worked per week at hourly rate, and              Average weekly tips or other income received for this job

Job 1: $ /hr              _            hrs/wk               _               $ tips/wk  _

Job 2: $ /hr               _            hrs/wk               _               $ tips/wk  _

Job 3: $ /hr               _            hrs/wk               _               $ tips/wk  _

Job 4: $ /hr                _            hrs/wk               _               $ tips/wk  _

Please list any additional earned income, including gross salary wages not listed above:

Unearned Income

12. List monthly amounts of ALL unearned income, for ALL members of household, such as unemployment compensation, Social Security, workers compensation, child support or disability payments.

Unearned income 1:

            $ /month   from   _

Unearned income 2:

            $ /month   from   _

Unearned income 3:

            $ /month   from   _

Please list any additional unearned income:

Other Financial Information

13. Do you pay child support?             No      Yes    If yes, $ /month   _

14. Do you pay alimony?             No      Yes    If yes, $ /month   _

15. What are your checking and/or savings account balances?

Checking:    Amount:   

Savings: Amount:

16. Do you own any of the items listed below? If so, list the value/balance of each:             

Stocks or bonds:

            $

Certificate of deposit:

            $

Retirement accounts:

            $

401K:

            $

Pension:

            $

Other Assets:

            $     Type of asset:

Real Estate:

            $ Type of Asset

Description of Legal Matter

*17. Brief description of legal matter:

__

_          

*18. What specifically do you want an attorney to accomplish for you?    

_

19. Name of opposing attorney (if known):           

20. Name/Location of Court (if known):           

21. Please describe reasons and justifications for reduced fee request and approval.  Please be sure to note all disabilities (if they are relevant to the reduced fee request); interruptions in income, excessive debts and expenses, etc.

_

22. What amounts, and on what terms would you be willing and able to pay for the legal services requested?

__________

23. Do you need an attorney who speaks a language other than English?             Yes   What language?

24. List the names of any attorneys you have already contacted and the results of those contacts:

To receive a reduced fee contract, you must agree to the terms, by checking the box below.

_____I understand that, no application is ever denied because of any membership in  a protected class or status. 

Please remember that some applications are denied because of time being unavailable, or because the attorney/office is unable to handle the requested type of case.

PLEASE PRESS THE SUBMIT BUTTON WHEN YOU ARE THROUGH!