Eligibility for Legal Services Form

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Eligibility for Legal Services Form
First, please check Eligibility Guidelines. Then fill out and submit the following form by printing and mailing or emailing it to
[email protected] Please be sure to also fill out and submit the Request for Legal Services Form.
Both this Eligibility Form and the Request for Legal Services Form must be received by Access Justice before we are able
to consider your request for legal assistance. Your request will be evaluated as soon as possible and, if accepted, may
require the payment of an appropriate retainer fee before legal assistance will be provided.
If you need help filling out this application, or if you want to apply over the phone, please call us at 612-879-8092 or toll free
at 1-877-999-AJ OK (2565). Client applications are taken Monday through Friday from 10 am to 3 pm. Sometimes you may have
a hard time getting through on the phones. We want to hear from you, so please keep trying or leave us a voice mail and we
will return your call as soon as we can.
In addition to providing the information below, a completed Request for Legal Services Form must accompany this form. If the
Request for Legal Services Form is not included, your request for legal assistance will not be considered until the completed
form is received.
All the information that you provide in this application is strictly confidential.
1) Applicant Information:
Your Name (First/MI/Last): _____________________________________________________________________________________
Your SSN: ____________________________________________________________________________________________________
Date of Birth (mm/dd/yyyy):_____________________________________________________________________________________
Gender: ____ M ____F
Mailing Address: ______________________________________________________________________________________________
City State Zip: ________________________________________________________________________________________________
Phone Numbers - Home: ______________________________________________ Work: ____________________________________
Cell: _____________________________________________ Other contact number: _____________________________________
E-mail Address:
______________________________________________________________________________________________
Is it safe to write you at the above address? ____ Yes ____ No
Is it safe to call you at the above phone? ____ Yes ____ No
If no, include safe contact info: _________________________________________________________________________________
Your marital status: ____ Single ____ Married ____ Divorced ____ Widowed ____ Other: _______________________________
Maiden Name: ________________________________________________________________________________________________
Former Name(s): ______________________________________________________________________________________________
Other Names you have gone by: _________________________________________________________________________________
Your race - check all that apply (OPTIONAL):
____ White ____ African-American ____ Asian or Pacific Islander ____ Hispanic ____ Native American
____ Other: __________________________________________________________________________________________________
Do you speak a language other than English at home?
____ No ____ Yes (if yes, which language): _______________________________________________________________________
Are you a Veteran of the U.S. Armed Forces? ____ Yes ____ No
Describe:_____________________________________________
2) Your household (list the names of each member of your household, their relationship to you
(for example, spouse, son, daughter, boy/girlfriend, etc.):
Full name
Relationship
Age
_____________________________________________
______________________________________________
______________
_____________________________________________
______________________________________________
______________
_____________________________________________
______________________________________________
______________
_____________________________________________
______________________________________________
______________
_____________________________________________
______________________________________________
______________
_____________________________________________
______________________________________________
______________
3) Household Income Information:
Please provide accurate documentation (e.g. copies of payment stubs, tax returns, government communications and/or similar
and recent documentation) to support the information supplied below.
Are you employed? ____ Yes ____ No
Name and address of most recent employer: ______________________________________________________________________
If yes, how much money do you earn each month before taxes? ______________________________________________________
Is anyone else in your household employed? ____ Yes ____ No
If yes, who? _________________________________________
If yes, how much money do he/she/they earn each month before taxes? _______________________________________________
Other income information (please list monthly amounts or zero (0) if none received):
Type of Income
You (Account #; Amount)
Other Person (Account #; Amount)
SSI:
_______________________________________
_________________________________________
Soc. Sec. Disability:
_______________________________________
_________________________________________
Soc. Sec. Retirement:
_______________________________________
_________________________________________
Child Support:
_______________________________________
_________________________________________
Spousal Maintenance:
_______________________________________
_________________________________________
Pension & Retirement Benefits: _______________________________________
_________________________________________
MFIP (welfare):
_______________________________________
_________________________________________
Veteran’s Benefits:
_______________________________________
_________________________________________
Unemployment:
_______________________________________
_________________________________________
Worker’s Compensation:
_______________________________________
_________________________________________
Other: _______________________________________
_________________________________________
4) Asset Information:
If you or anyone in your household has any of the following, please fill in the value and provide documents for each item listed.
For example, if you or someone in your household has a checking or saving account and there is no money in it, enter zero (0):
Type of Assets
You (Account #; Amount)
Other Person (Account #; Amount)
Checking, Savings, Cash:
_______________________________________
_________________________________________
Checking account:
_______________________________________
_________________________________________
Saving account:
_______________________________________
_________________________________________
CD’s:
_______________________________________
_________________________________________
Stocks or Bonds:
_______________________________________
_________________________________________
IRA:
_______________________________________
_________________________________________
Other: _______________________________________
_________________________________________
Other: _______________________________________
_________________________________________
Vehicles (please list all vehicles):
Year
Model
Value
Money Owed
___________
________________________________
_________________________
__________________________________
___________
________________________________
_________________________
__________________________________
Recreational Equipment (boats, guns, jet skis, horses, motorcycles, etc.):
Year
Model
Value
Money Owed
___________
________________________________
_________________________
__________________________________
___________
________________________________
_________________________
__________________________________
Real Estate:
Do you: ____ own a home? ____ have a mobile home? ____ rent apartment or home? (Monthly Rent $ ____________________)
____ live with relatives? ____ live with friends? ____ other __________________________________________________________
If you own a home, fill in information below.
Description (physical address): ___________________________________________________________________________________
Value: ______________ Money Owed: ________________ Mortgage Holder & Account # : _______________________________
Property Tax (please include copy of statement): ___________________________________________________________________
Do you own any property other than where you live? ____ Yes ____ No (If yes, please describe other property below).
Description (physical address): ___________________________________________________________________________________
Value: ______________________________ Money Owed: _________________________________
5) Debt Information: (individual and/or joint)
Credit Card (name, # and amount): _______________________________________________________________________________
Credit Card (name, # and amount): _______________________________________________________________________________
Credit Card (name, # and amount): _______________________________________________________________________________
Loan (company, #, amount, monthly payment): _____________________________________________________________________
Loan (company, #, amount, monthly payment): _____________________________________________________________________
Other: _______________________________________________________________________________________________________
I/we submit and sign this form by stating that the information provided is complete, true and accurate in every material respect and that , if found to be
otherwise, Access Justice may decline to represent me/us and/or immediately withdraw from any further representation.
Print Name: ________________________________________________________ Date: _____________________________________
Signature: ____________________________________________________________________________________________________
6) Please submit this signed, dated and completed form and your signed and dated Request for Legal Services Form to:
Access Justice - PO Box 3654, Minneapolis, MN 55403-9998
Phone: 612.879.8092 Toll Free: 1.877.999.AJ OK (2565) Fax: 612.879.8707 E-Mail: [email protected]
*Access Justice is a Service mark of Access Justice, PSC