Application for Legal Services

Please fill out the form below.

IMPORTANT When you have completed and submitted the application below, you must fill out the Authorization and Certification Form. Click Here to complete this form.

Have you applied for Judicare before?	Yes No
If Yes, under what name?

* Name:
* Address:
* City:		County:	* Zip Code:
Phone:	Home:
	Work:
	Cell:
Date Of Birth:

Contact Person:

Name:

Phone:

List the first and last names of the people living in your household:
First Name	Last Name	Date Of Birth	Relationship

List the first and last names of your minor children not living in your household:
First Name	Last Name	Date Of Birth

List the first and last names of the biological parent, other than yourself, for each child listed above.:
First Name	Last Name	Name of Children in Common

Your Sex:
Your Race:		If Other:
Your Marital Status:
Your Spouse's Name:		Address:

* What is your legal problem?
When is your next court date?
In which county and state is your legal problem?
What is the name of the person or agency your legal problem is against?

Are you a victim of crime, sexual assault, domestic violence or abuse such as verbal, emotional, financial or physical?	Yes No
If Yes, by whom?

If you are a victim of violence, please indicate what other mailing address you want us to use:

Address

City

State

Zip Code

Are you a Veteran?

Yes No

Is some or all of your or your spouse's income primarily used for medical or nursing home expenses?	Yes No
If Yes, you will be asked to provide documentation.

Are you a U.S. citizen?	Yes No
If Yes, you will be required to attest to this in writing.
Your application must be submitted to the Judicare office for consideration. Please provide a photocopy of the front and back sides of your resident alien card, passport, or other documents regarding your admission to the United States.

Are you self-employed or do you own and operate a farm or business?	Yes No
*If Yes, you must mail a copy of your most recent Federal Income Tax return.*

Gross Monthly Household Income: Include all income before taxes or deductions from wages and salaries, self-employment, and all other income received for all members of your household.
	Applicant	Spouse	Other Household Members	Total
a. Wages/Salaries/Self-employment
b. Social Security/SSD/SSI
c. Welfare/W-2
d. Unemployment or Worker's Comp.
e. Child Support/Alimony
f. Other sources of income
g. Per Capita
Total:

Monthly Household Expenses: List only those expenses that you or your household members are currently paying.
	Applicant	Spouse	Other Household Members	Total
a. Rent/Mortgage
b. Child Support
c. Child Care
d. Medical Insurance Premiums

Assets: Include the value of all assets listed below. List only the equity value. Equity means the value of the item on today's market minus the amount owed on that item.
	Applicant	Spouse	Other Household Members	Total
a. Cash/Checking/Savings/CDs/ Stocks/Bonds
b. Trusts
c. Life Insurance with Cash Surrender Value
d. Guns/Boats/ATVs/Snowmobiles/Motor Homes and Other Similar Items
e. Real Estate Other than Homestead
Total:
IMPORTANT: Again, you must fill out the Authorization & Certification form after completing this application.

I have printed, signed, and mailed in the Authorization and Certification Form. Click here to print and view the Authorization and Certification Form form.	Yes No
* Validation:

Please press the Submit button only once.