Please Print:

Name: _______________________________ Address: _________________________________
City: ___________________ County: ________________________ Zip Code: _______________
Phone (Home): _______________________ (Work): ______________________ (Cell):____________________
Age: ______ Date of Birth: _____________ Social Security Number: ___________________
Someone who can always contact you: Name: _______________________________ Phone: ________________

1.(a) List the first and last names of the people living in your household:

Name: First	Last	Age	Relationship

(b) List the first and last names of your minor children not living in your household:

Name: First	Last	Age

2. Circle your sex:  Male  Female
3. Circle your race:  White  Black  Hispanic  Native American  Asian  Other: ___________
4. Circle your marital status:  Single  Married  Widowed  Divorced  Separated
5. Spouse's Name & Address: ______________________________________________

6. Do you have a legal problem? (   ) Yes (   ) No.  If Yes, what is your legal problem? (You do not need to answer this question and should not answer this question if your legal problem or dispute is with the agency or individual assisting you with this application.)
_________________________________________________________________________
_________________________________________________________________________

7. Who is your legal problem against? _____________________________
8. Are you a victim of domestic violence? (   ) Yes (   ) No.  If Yes, by whom?_____________________
9. Is some of all of your income or spouse's income primarily used for medical or nursing home expenses? (   ) Yes (   ) No.  If yes, please provide documentation with this application.

10. ARE YOU A U.S. CITIZEN? (   ) Yes (   ) No.  If yes, complete #11 below. 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.

11. I hereby attest that I am a United States citizen. Please sign and date in the spaces provided below.

X APPLICANT'S SIGNATURE ________________________________ Date ___________

PLEASE COMPLETE THE FINANCIAL WORKSHEET

Please answer all the following questions so that we can determine your financial eligibility for our services. Any missing information will delay an eligibility determination.

12. Are you self-employed or own and operate a farm or business? (   ) Yes (   ) No.  If yes, you must provide a copy of your most recent Federal Income Tax return with this application.

13. 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 Member	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. Add lines 13 (a - f) : .........................................................................................................13g $________

14. Monthly Household Expenses: List only those expenses that you or your household members are currently paying.

	Applicant	Spouse	Other Household Member	Total
a. How much is paid out for rent or mortgage?	$	$	$	$
b. How much is paid out for child support?
c. How much is paid out for child care?
d. How much is paid out for medical insurance premiums?

e. Add lines 14 (a - d) : ....................................................................................................14e $ (________)

15. Total Monthly Income (subtract line 14e from 13g)...................................Total: ________

16. 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 Member	Total
a. Cash/Checking/ Savings/CD's/Stocks/Bonds	$	$	$	$
b. Pensions/IRA's/ Trusts
c. Life Insurance with Cash Surrender Value
d. Guns/Boats/ ATV's/Snowmobiles/ Motor Homes and Similar Items
e. Real Estate Other Than Homestead

17. Total Assets ( Add lines 16 a - e ) : .........................................................Total: ____________

18. I hereby apply for legal assistance from Wisconsin Judicare, Inc. I hereby certify that the information supplied above is true and accurate to the best of my knowledge and belief. I authorize Wisconsin Judicare, Inc. to verify by reasonable means the financial information I have provided. I understand any future changes to the above information must be reported to the Wisconsin Judicare Office.

19. LIMITED AUTHORIZATION FOR DISCLOSURE OF CONFIDENTIAL INFORMATION TO FEDERAL AUDITORS AND MONITORS: Federal law requires Wisconsin Judicare, Inc. to give federal officials that are auditing or monitoring Wisconsin Judicare, Inc.'s activities the following information: your name and records containing your eligibility for services by Wisconsin Judicare. If legal assistance is provided to you, including counsel and advice or brief service, Wisconsin Judicare, Inc. may be required to provide these federal officials the advice that was provided to you by the Judicare attorney, any general information about the nature of your case, a written statement of facts signed by you upon which a lawsuit filed by you would be based, your retainer agreement with Wisconsin Judicare and records concerning financial eligibility and client trust funds. You hereby agree that Wisconsin Judicare, Inc. may disclose the limited information listed above to the federal officials that audit or monitor the activities of Wisconsin Judicare, Inc. and any independent auditor or monitor receiving federal funds to conduct such auditing or monitoring. The above authorization was read, or read to me, and I understand and expressly agreed to it.

X APPLICANT'S SIGNATURE ________________________________ Date ___________

20. Grievance Procedure: If my financial application or my case is not accepted, I understand that I may appeal this decision. Please Click Here for a full Grievance Procedure, or request a copy from the Judicare office.

PLEASE COMPLETE THE ENTIRE APPLICATION
All Blanks must be filled in, any missing information will result in your application being returned to you for completion without an eligibility determination. Please Download a Hard Copy of this Web Page and Return it to Wisconsin Judicare once You have Completed the Entire Application.

Online Application last updated 8/29/06.