Legal Aid of East Central Indiana client intake form
Client Intake Form
STEP 1: Fill out this application to the best of your ability
STEP 2: Review information. Agree to retainer/citizenship/release
STEP 3: Submit
Legal Aid of East Central Indiana will review your application for program qualification. Please note that qualification with Legal Aid of East Central Indiana does not guarantee placement with a pro bono attorney. If you qualify, the Legal Aid of East Central Indiana office will attempt to refer your case. If a referral is made, the decision to accept you as a client is solely determined by the attorney.
If you have an emergency or court deadline you should make every attempt to obtain private counsel of your own choosing.
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Please review your answers
Date
Name
Do you have previous names?
Address 1
Address 2
Email
Phone and Best time to call
Can you read and write?
How long have you lived in Indiana?
What is you County of Residence?
How long have you lived in the county?
How did you hear about Legal Aid of East Central Indiana?
Have you ever contacted Legal Aid of East Central Indiana before?
Gender
Date of Birth
SSN
Marital Status
Date of Marriage?
Date of Separation?
Are there children in this relationship?
Citizen
Disability
Pregnant
Pending criminal matter?
Do you have children not listed above?
Number of individuals in household
How many people do you support?
Do you own a home?
Do you rent?
Income from work:
Income from child support:
Income from Food Stamps:
Income from Soc. Sec. Income:
Income from Soc. Sec. Disability:
Income from Supplemental Security Income:
Income from Temp. Assistance:
Income from Other Income:
How much cash do you have presently?
How much do you have in savings?
How much pension do you presently have?
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?
Tax refund?
Do you pay child support?
Court orders?
Opposing Party Type:
Opposing Party?
Area of need:
Narrative
Applications will not be considered unless accompanied by completing the following Retainer Agreement, Declaration of Citizenship, and Client Authorization and Release for Legal Aid of East Central Indiana.
Retainer Agreement
"I have requested referral to a private attorney through the Legal Aid of East Central Indiana, pro bono legal aid program for representation.
I understand that eligibility for services does not guarantee a referral by Legal Aid of East Central Indiana, to a pro bono attorney.
If Legal Aid of East Central Indiana, makes a referral, I understand that the pro bono attorney will review and evaluate my case and determine whether or not to accept me as a client. I further understand that Legal Aid of East Central Indiana, has absolutely no authority over the pro bono attorney's decision to accept or decline legal assistance. The nature of the services to be provided will be determined by the pro bono attorney on an ongoing basis.
I may terminate this agreement at any time. I understand that I have the responsibility to inform Legal Aid of East Central Indiana, of any change in my household, income, resources, and contact information. I understand and agree that if I become financially ineligible for representation by Legal Aid of East Central Indiana, they may terminate this agreement. Additionally, if I become ineligible for services for any reason specified in federal law or federal regulation, Legal Aid of East Central Indiana, may have to withdraw the referral made to the pro bono attorney."
Declaration of Citizenship
"I hereby declare that I am a citizen of the United States."
Client Authorization and Release
"I authorize Legal Aid of East Central Indiana, to release records and information pertaining to my case to the pro bono attorney(s)."
