Address: _____________________________________________________
City: _______________________ State: __________ Zip Code: ___________
Phone: _________________ (home) _____________________ (work)
Contact Person Name & Number: ________________________________________
Marital Status:
___ Married ___ Single ___ Divorced ___ Separated
Husband/Wife's name: _____________________________ Age: _______
Children (or other dependents): Give name and ages ________________
__________________________________________________________
__________________________________________________________
With whom do you live? Name and Relationship to you ____________
__________________________________________________________
Who provides financial assistance to you or your family? Name and Relationship to you
__________________________________________
___________________________________________________________
Are you on welfare benefits or any type of public assistance?
____ yes ____ no
If yes, what and how much do you receive _______________________
__________________________________________________________
How much assistance do you receive from sources other than you or your spouse's (cohabitant's) employment: Identify Amount and Source ______
___________________________________________________________
___________________________________________________________
Employer: __________________________________________________
Address: ____________________________________________________
(If both you and your spouse are employed, identify both)
Your gross wages: $ __________ per ___________
Your take home: $ __________ per ___________
Spouse's (cohabitant's) gross wages: $ ________ per ________
Spouse's (cohabitant's) take home: $ ________ per ________
Average weekly/monthly expenses: ____________________________
_________________________________________________________
_________________________________________________________
List all motor vehicles or real estate which you or your spouse own and state how much each is worth:
________________________________
_________________________________________________________
List any debts you and your spouse now have and the amount of each debt:
____________________________________________________________
Is there any family member, friend, or other person who could provide you with some financial assistance? ______________ If so, identify such person: ____________________
Nature of legal problem: ________________________________________
State whether your legal problem is an emergency matter. If so, please describe the nature of the emergency: ______________________________
_____________________________________________________________
If accepted for pauper assistance, I understand that I will be expected to pay some money to my attorney for his services and I would be able to pay $ _________ per week/month for his/her help. I also understand that the attorney is not obligated to agree to assist me with this matter.
I have received a copy of the sheet of Insructions and Important information, and I have read and understand them. I am willing to abide by the rules of the program and any terms and conditions imposes on any appointment.
__________________________ ______________
(Signature) (Date)
FOR OFFICIAL USE ONLY
____ Accepted _____Denied (List reason for denial under Conditions)
Conditions Imposed: ___________________________________________
____________________________________________________________
____________________________________________________________
Attorney assigned: ____________________________________________
Address: _____________________________ Phone: ________________