Application for Legal Services

Please fill out the form below.

IMPORTANT - YOU MUST FILL OUT THE Authorization and Certification Form BEFORE FILLING OUT THE FORM BELOW

I have printed, signed, and mailed in the Authorization and Certification Form.	Yes No
Have you applied for Judicare before?	Yes No
If Yes, under what name?
Judicare Card #

For your safety, what other mailing address do you want us to use if different than above?

Address

City

State

Zip Code

Contact Person:

Name:

Phone:

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

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

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

* 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 the victim of domestic violence?	Yes No
If Yes, by whom?

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.
If No, a Judicare card will not be issued. 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
(1) Add lines a-g:

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
(2) Add lines a-d;

Total Monthly Income: - Subtract line (2) from line (1):

Expenses may not be counted to calculate eligibility.

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. Pensions/IRAs/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
Add lines a-e:
IMPORTANT: Again, you must fill out the Authorization & Certification form prior to submitting this form.

* Validation:

Please press the Submit button only once.