First Name: *
Middle:
* Last Name:
*
Do you have any prior names?
Address 1: *
Address 2:
City: * State: * Zip: *
Email:
Phone: * Additional Phone: Best time to reach by phone?
Can you read and write? * How long have What is your county of residence? *
How long have you How did you hear about District 6 Access to Justice? Have you ever contacted District 6 before?
Gender: *
Date of Birth: *
Martial Status: * If you are married, how long have you been married?
If married, please list your spouse's name and contact information.
Are there any children in this relationship? *
Citizen? * Do you have any disability? *
Are you pregnant? *
Do you have a pending criminal matter? *
Do you have children?
*
Number of individuals living in your household? *
List the name of everyone living in your household and his/her relationship to you (ex: child, boyfriend, parent, etc.).
How many people do you support? * Do you own a home? * If you don't own a home, do you rent, reside with family, etc.?
In dollars and cents, list the amount of your pre-tax gross income that comes from the following types of income sources for everyone living in your household:
Amount: Weekly or Monthly?
Work:
$
Child support:
$
Food stamps:
$
Social Security Income:
$
Social Security Disability:
$
Supplemental Security Income:
$
Temporary Assistance:
$
Other:
$
Please indicate the present value of the following assets.
How much cash do you have presently?
$
How much do you have in savings accounts presently?
$
How much pension do you have presently?
$
What is the value of the vehicle(s) you own?
$
What is the value of the home you own?
$
What is the value of any other realty you own?
$
What is the value of any other property you own?
$
If you have received a tax refund in the last 3 months, please list the amount.
$
Do you pay child support? * If you pay child support, how much are you ordered to pay?
$
Arrearage?
Has a case been filed for this matter?
If yes, what is the Cause Number for this case?
What is the county of the case?
Who is the opposing party in the case?
Attorney for opposing party?
Please select the area(s) of law for which you need assistance: *
Narrative. Please tell us everything about this situation. What is the problem, and why do you think you need an attorney?
