LEGAL CLINIC APPLICATION

LEGAL CLINIC APPLICATION
Name *

First Name Last Name
Property Address & Apt # *

Input Address and Apt #

Street Address Line 2

City State / Province

Postal / Zip Code
Phone: *
Alternate Phone:
Date of Birth *

Month Day Year
Date
Age: *
Social Security #: *
Sex: *
Primary Language: *
Ethnicity/ Race: *
Household Size: *
Name of Family Member 2 *
Age of Family Member 2 *
Place of Employment/ School *
Monthly Income *
Type of Income
i.e., Employed, SSI?SSDI. Unemployment Insurance
Name of Family Member 3 *
Age of Family Member 3 *
Place of Employment/ School *
Monthly Income *
Type of Income
i.e., Employed, SSI?SSDI. Unemployment Insurance
Name of Family Member 4 *
Age of Family Member 4 *
Place of Employment/ School *
Monthly Income *
Type of Income
i.e., Employed, SSI?SSDI. Unemployment Insurance
Name of Family Member 5
Age of Family Member 5
Place of Employment/ School
Monthly Income
Type of Income
i.e., Employed, SSI?SSDI. Unemployment Insurance
Name of Family Member 6
Age of Family Member 6
Place of Employment. School
Monthly Income
Type of Income
i.e., Employed, SSI?SSDI. Unemployment Insurance
Assets: Monthly Expenses:
Cash *
Mortgage/ Rent *
Other *
Other *
Total Assets *
Total Expenses *
I certify that the information I have provided above is true and correct to the best of my knowledge.
Signature *

Clear
Date *

Month Day Year
Date
I attest that I am a United States citizen or legal resident of the United States.
Printed Name *
Date *

Month Day Year
Date
Signature *

Clear
Rent or Mortgage Information
Property Name: *
Property Address *

Street Address Line 2

City/State/Zip
Office Phone #: *
Manager/ Owner: *
Manager Address *

Street Address Line 2

City/State/Zip
Manager Phone #: *
TAA *

Subsidized TAA Oral Oral Lease Period (i.e., Jan - Dec )
Lease Period: (i.e., Jan - Dec ) *
Security Deposit Amt: *
Pet Deposit: *
Monthly Rent/ Mortgage: *
Please briefly describe problem *
CONSENT FOR WORKSHOP CONSULTATION
Housing Crisis Center does not provide legal representation through the workshop consultation. I understand that, during the course of my consultation, I will receive information about the laws and may receive copies of the laws and or forms that may assist me in resolving my problems, in addition to the advice I receive. I also understand that the volunteers advising me may be an attorney or law student under the supervision of a law professor or a licensed attorney. I have read the foregoing and hereby consent to be advised under the conditions as set forth above. I also understand that the attorney advice or consultation does not create any lawyer/client relationship outside of the workshop.
Signature: *

Clear
Printed Name: *
Date *

Month Day Year
Date
Should be Empty:

LEGAL CLINIC APPLICATION

Rent or Mortgage Information

CONSENT FOR WORKSHOP CONSULTATION