Legal Aid of East Central Indiana 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.

* Indicates a required field

Date

* First Name

* Middle Name

* Last Name

Do you have prior names?
Yes No

If yes, please enter your full prior name:

* Address 1

Address 2

* City

* State

* Zip

* Phone

Additional Phone (Safe Phone)

Best time to reach by phone:

* Can you read and write?
Yes No

How long have you lived in Indiana?

* What is your county of residence? Select from the dropdown.

How long have you lived in your county of residence?

How did you hear about Legal Aid of East Central Indiana?

Have you ever contacted Legal Aid of East Central Indiana before?
Yes No

* Gender:
Male Female Prefer Not To Answer

* Date of Birth: For example January 13, 1995 would be 01/13/1995

* Social Security Number:

* Marital Status:
Married Single Divorced Divorced Pending

If you are married, how long have you been married? Please list date of marriage in box below.

Also, if married, please list your spouse's name and contact information including: date of birth, gender, social security number, contact phone, and email.

If separated, how long have you been separated? Please list date of separation in box below.

* Are there children in this relationship?
Yes No

If yes, please list each child's name, date of birth, and social security number:

* Citizen?
Yes No

* Do you have a disability?
Yes No

If yes, please describe:

* Are you pregnant now?
Yes No

* Do you have a pending criminal matter?
Yes No

If yes, please describe:

* Do you have children other than any listed above?
Yes No

If yes, please list each child's name, date of birth, and social security number:

* Number of individuals in your household:

List the full name, date of birth, and relationship of everyone living in your household.

* How many people do you support?

* Do you own a home?
Yes No

If you do not 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 (These fields are required).

Note: Your application cannot be processed if you enter "0" for all fields in this section:

*Work:
Weekly Monthly
                     $

*Child Support Received:
Weekly Monthly
                     $

*Food Stamps:
Weekly Monthly
                    $

*Social Security Income:
Weekly Monthly
                  $

*Social Security Disability:
Weekly Monthly
               $

*Supplemental Security Income:
Weekly Monthly     $

*Temporary Assistance:
Weekly Monthly                   $

*Other:
Weekly Monthly                     $

Please indicate the present value of the following assets (required).

*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?
Yes No

*How much are you ordered to pay?

*Arrearage?
Yes No

Has a case been filed for this matter?
Yes No

If yes, what is the Case Number for this case?

What is the county of the case?

* Is the opposing party a person or organization?
Individual Organization

* If the opposing party is a person, please list the person's name and date of birth. If the opposing party is a business, please list the business name and contact number.

Attorney for opposing party?

Please select the area(s) of law for which you need assistance (you are required to select at least one area from below):

Divorce/Separation

Guardianship

Power of Attorney

Mortgage Foreclosure

Visitation

Custody

Support

Wills, Estates, etc.

Landlord/Tenant

Adoption

Name Change

License Reinstatement

Other

* Narrative. Please tell us everything about this situation. What is the problem, and why do you think you need an attorney?

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

Client Intake Form

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 (These fields are required).

Note: Your application cannot be processed if you enter "0" for all fields in this section:

Please indicate the present value of the following assets (required).

Please select the area(s) of law for which you need assistance (you are required to select at least one area from below):

Legal Aid of East Central Indiana Providing FREE legal assistance for Indiana residents in need

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