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  • PLEASE READ BEFORE YOU CONTINUE:

    Security of your sensitive information provided in this form is important to us. Therefore, we cannot SAVE your entry to complete at a later time. 

    Please have ALL your information ready to input/upload and allow time to complete this form. (Full Name(s), Documents, Dates, etc.)

  • APPLICATION FOR LEGAL SERVICES

    CUSTODY AND SUPPORT

     

  • PLEASE ANSWER ALL REQUIRED QUESTIONS IN THIS APPLICATION. THE FOLLOWING INFORMATION IS FOR OUR USE ONLY. WE WILL LET YOU KNOW IF YOUR APPLICATION HAS BEEN ACCEPTED WITHIN FOUR WEEKS.

  • Do you have a pending case in court?
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  • Was the case filed by you or the other parent?
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  • If the case was filed by the other parent and you were served, did you file an answer?
  • If the case was filed by you, did you have an attorney?
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  • Are you receiving services from Family Violence Prevention Services?
  • Do you have a copy of your pleadings and court orders?
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  • Which copies of EVIDENCE do you have? (Check all that apply)
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  • YOUR INFORMATION

  • Does the other parent know where you are residing?
  • Do you want your address kept confidential?

  • Please provide your contact information below where our agency can reach you.

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  • Is this Home Phone Number safe?
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  • Is this Work Phone Number safe?
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  • Is this Cell Phone Number safe?
  • Is this Email Address safe?
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  • YOUR INFORMATION

    CONTINUED
    1. Below, please provide some information about yourself. If you do not have a Social Security Number or Driver’s License, please write “N/A” in the appropriate space(s).
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  • Are you a U.S. Citizen?
  • Do you have a VISA, Work Pass or Other?

  • Are you a Permanent Resident?
  • Are you Undocumented?
  • Are you currently in the military?
  • Active Duty or Reserves?
  • Are you retired or separated from the military?
  • Were you honorably discharged?
  • Are you employed?

  • FAMILY VIOLENCE

  • Do you have a Protective Order?
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  • Do you feel you need a Protective Order?
  • Have you ever filed charges against the other parent?
  • Are you aware of any scheduled court dates?
  • Have you been to court for any reason?

  • Incident Information

  • To assist our agency in assessing the urgency of your case, please state the nature of the violence that happened to you and/or your children. Give the month, day, and year of each incident and explain what the adverse party did. Please note if there are police reports and, if so, give the case numbers. Please include ALL the incidents of violence you experienced, including those that are not very recent and those that did not involve the police. If you do not remember the dates of incidents of violence, please write “N/A” in the appropriate space(s). If the violence you experienced occurred over a long period of time or constantly during your relationship and you cannot recall a specific incident, please record the long term mistreatment and explain the frequency with which it happened.

  • Incident #1

  • Were the police contacted?
  • Would you like to report a 2nd Incident?

  • Incident #2

  • Were the police contacted?
  • Would you like to report a 3rd Incident?

  • Incident #3

  • Were the police contacted?

  • OTHER PARENT INFORMATION

  • Can the other parent be served at the above address?
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  • Is the other parent currently in the military?
  • Active Duty or Reserves?
  • Is the other parent retired or separated from the military?
  • Was he/she honorably discharged?

  • Other sources of income for the other parent:

  • Is the other parent a U.S. Citizen?
  • Does the other parent have a mental or physical condition?
  • Has the other parent ever been arrested?
  • Have details of a 2nd known arrest?
  • Have details of a 3rd known arrest?
  • Have details of a 4th known arrest?
  • Have details of a 5th known arrest?

  • RELATIONSHIP INFORMATION

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  • Are you and the other parent still living together?
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  • Has he/she visited the child/ren?

  • RELATIONSHIP INFORMATION

    Continued

  • List all of your minor children, even if they have different parents and even if they are not currently living with you:

  • INFORMATION ABOUT CHILDREN

  • Add Child #2?
  • Add Child #3?
  • Add Child #4?
  • Add Child #5?
  • Add Child #6?
  • Add Child #7?
  • Do you want custody of the minor children you have with the other parent?
  • Does the other parent want custody of your minor children?
  • Are you pregnant?
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  • Do all of the children you are seeking custody of have their father’s last name on their birth certificate?

  • Name of any children with mental/physical disabilities:

  • Does any child own property (such as savings account, car, land, or anything of value)?
  • Has anyone from CHILD PROTECTIVE SERVICES ever contacted you?
  • Have you contacted the Attorney General’s office for child support?
  • Have you or the other parent been to court for child support?
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  • INSURANCE

  • Does the other parent have life insurance on himself/herself or the children?
  • Do you have medical insurance on yourself and the children?

  • MODIFICATION INFORMATION

  • Do you have an existing custody or child support order?
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  • PROPERTY INFORMATION

    If you or the other parent own any of the following property, please check all that applies:
  • Home

  • Car

  • Retirement Account

  • Savings Account

  • Certificate of Deposit (CD)

  • Thrift Savings Plan

  • Rental Property

  • YOUR FINANCIAL INFORMATION

    The following information will be used to determine financial eligibility and to prepare an affidavit. If we are able to accept your case, you will be required to sign and notarize the affidavit, so that you will not have to pay filing fees. This information MUST be accurate.

  • MONTHLY INCOME

  • If you were referred to our agency, how did you find out about our services?

  • By signing and submitting this form you certify that the information provided herein (this web form) is true and correct to the best of your knowledge.

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