Intake Form - Bilingual

149 South Genesee Street
Waukegan, IL 60085
phone: 847.244.4900
text: 847.908.5420

www.coalitionlegal.org
info@coalitionlegal.org

Expungement Help Desk Client Intake Sheet
Step 1: Fill Out this Intake Form
Name*

First NameMiddle NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*

Area CodePhone Number
Email
example@example.com
Additional Contact Name

First NameLast Name
Additional Contact Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Additional Contact Phone Number

Area CodePhone Number
1. Gender*
2. Date of Birth*

MonthDayYear
Date
3. Race/Ethnicity*

African AmericanHispanicWhiteOther
4. Were you born in the United States?*

YesNo
5. If you were not born in the United States, what is your status?

Naturalized citizenLegal Permanent Resident (LPR)UndocumentedOther
6. Are you currently employed?*

YesNo
Name of Employer
Address of Employer

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number of Employer

Area CodePhone Number
Current Hourly Wage:

Income


Current Wage (per hour)
Number of hours worked per week
Annual Salary

7. Would you like to be referred to additional resources to explore employment options?*

YesNo

8. Number of dependents in your household that you support

	Number
Under 18
Over 18

9. Other names you have used
Criminal Background Information
10. Have you ever been arrested by any policing authority other than in Lake County, IL*

YesNo
If yes, for each arrest please state: The approximate date of arrest, county of arrest, city or place of arrest, general nature of the charges, and the outcome of the arrest. If you have county or city of arrest and specific case numbers, please list them:
The court will want to know that you have rehabilitated yourself and are using this process to help you move on. What is your goal for seeking legal help with your criminal record?

Find employment or better housingGet housing assistancePersonal motivation to clear recordEnter an educational or training programAssist with immigration status (see above)Other
Please add any additional information here
Eligibility for Waiver of Fees

Lake County charges a $72 filing fee for each criminal case. However, you may qualify for a waiver of that feeif you have received 1 or more of the benefits listed below in the past 4 weeks:

·      Supplemental Security Income (SSI) (Not Social Security)

·      Aid to the Aged, Blind and Disabled (AABD)

·      Temporary Assistance to Needy Families (TANF)

·      State Children & Family Assistance

·      Food Stamps (SNAP)

·      General Assistance (GA)

·      Transitional Assistance
Have you received 1 or more of the benefits listed above in the past 4 weeks?*

YesNo
How were you referred to Coalition Legal?

A FriendSaw a flyerSaw link to your website on the webOther
Name of the friend who referred you:
Please tell us where you saw the flyer:
Please tell us where you found the link:
Please choose one of the options below to submit your application*

I am a US citizen.I am not a US citizen.
Acceptance of your Application

Welcome to the Coalition Legal Help Desk, an independent program affiliate of the Coalition to Reduce Recidivism. After you complete this form, there may be a wait before you hear from the attorneys as we operate on a first come, first served basis. We will tell you if we are going to represent you and the next steps in the process if we do. Please be patient.

Terms and Conditions of Service

I understand and agree that the persons advising me may include staff attorneys, volunteer attorneys, and law students. I also understand and agree that the advice and drafting of legal instruments may be given by a paralegal, a Rule 711 supervised senior law student, or a law school graduate. In all cases, however, the handling of my criminal record will be supervised by a staff attorney.

Discretionary Remedy

I understand that, whether a case is eligible under Illinois law, the ultimate decision on whether to grant my petition is made by a judge assigned to the matter, who may deny any petition for discretionary reasons.

Use of Personal Information

I understand that Coalition Legal collects and maintains both demographic and criminal history information for two purposes: (1) for representation before the Court in hearings; and (2) for advocacy, policy and research purposes. Data is always reported upon in the aggregate and not specific to any individual. Files are maintained electronically at Coalition Legal. I understand that identifiable information about me or my criminal record will be kept strictly confidential and is only available to Coalition Legal staff and volunteers.

Read, Understood and Agree to the Terms and Conditions of Service

I have read the above information and I understand and agree to the terms and conditions of the legal services provided by Coalition Legal.
Print Your Name*
Signature: I am agreeing that this checked box constitutes my signature and agreement that the information in this application is true and correct, and my acceptance of the Terms and Conditions of Service.*

I agree
Date

MonthDayYear
Date

Expungement Help Desk Client Intake Sheet

Step 1: Fill Out this Intake Form

Criminal Background Information