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    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.

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  • YOUR INFORMATION

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

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  • YOUR INFORMATION

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    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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  • FAMILY VIOLENCE

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  • 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

  • Incident #2

  • Incident #3

  • OTHER PARENT INFORMATION

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  • Other sources of income for the other parent:

  • RELATIONSHIP INFORMATION

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  • RELATIONSHIP INFORMATION

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  • 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

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  • Name of any children with mental/physical disabilities:

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  • INSURANCE

  • MODIFICATION INFORMATION

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  • PROPERTY INFORMATION

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







  • 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


  • 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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