Salesforce - FSJ Service Request Form

This Form Has Moved!
You can now request your FreeState Justice pro bono legal services, register for upcoming events, and more at our new Intake Form here.
DO NOT SUBMIT THIS FORM!
Please visit our updated form at https://form.jotform.com/243034377994062
Is this a request for legal services or to report an incident?*

Legal servicesIncident report
Date

YearMonthDay
Are you completing this form for yourself or on behalf of someone else?*
Please select.
Prefix
Prefix or title.
First Name*
Chosen name
Middle Name
Optional, chosen name
Last Name
Required only if requesting Legal Services, chosen name
Date of Birth*

MonthDayYear
Pronouns*

they/them/theirsshe/her/hershe/him/hisOther
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Preferred methods of contact*

EmailPhone callPhone (SMS) textingOther
DoNotCall
DoNotEmail
DoNotText
Phone Number

Area CodePhone Number
Email Address

Confirmation EmailPlease confirm your email address.
Zipcode*
This helps determine eligible services.
County*
This helps determine eligible services .
Do we have permission to contact another person if we cannot reach you?*
If Yes, please provide the contact information for a person we can contact if we are unable to reach you.
Additional Contact Name*
Relationship to additional contact*
Additional Contact Phone Number*

Area CodePhone Number
Additional Contact Email*
example@example.com
For legal services, please indicate the issue(s) you are looking for support on. If the legal services you are looking for are not below, please select Other.*

Name change onlyGender marker change onlyName & gender marker changeEmployment issuesHealthcare or health insurance issuesDiscrimination in public services or accommodationsHousing issuesLiving will or advance directivesDivorceDomestic or intimate partner violenceHarassment, assault, or violenceFamily law (custody, parenting rights, etc.)Arrest records expungementsProtective/Peace OrderOther
Please explain your legal issue or need for resource assistance. Provide as many details as possible. Please note if you will be attending an upcoming clinic or event.*
Why are you requesting help from Freestate Justice?
What is your desired outcome? What do you hope to achieve?*
Why are you requesting help from Freestate Justice?
Do you have any physical/electronic material (letters, copies of communication, mail, etc.) related to your request you can share?
This helps us process your request more quickly. If you're doing a name change, please attach a copy of your ID and/or birth certificate, and any prior name change orders.
Please upload any relevant materials.*

Browse Files
This helps us process your request more quickly. Cancelof
Have you received services from FreeState Justice or FreeState Legal Project before?*
This helps us find previous case files.
If yes, can you briefly describe previous services?*
How have we worked with you before?
Do you identify as lesbian, gay, bisexual, transgender, queer, questioning, intersex, and/or asexual (LGBTQIA+)?*
This helps us determine eligible services.
Do you feel that LGBTQIA+ discrimination or bias is involved? *
This helps us determine eligible services.
In the past three years, have you a been a victim of abuse, violence, or crime?*
This helps us determine eligible services.
Have you already filed a report related to this issue?*
This helps us determine eligible services.
Monthly Income Disclosure & Verification

FreeState Justice provides pro-bono legal services for individuals and families of low or limited income. This disclosure helps us determine eligible services.

If you have any questions or concerns regarding this portion of the application, please contact FreeState staff at (410) 625-5428.

Household Size
Your household is determined by the number of people that live with you (including you) and with whom you share finances. For example, a roommate who pays some of the rent and utility bills but who purchases his own groceries and whose money is separate from yours would not be considered part of your household. A roommate, partner, or family member who pays for some or all of the rent and who provides you with money for personal expenses would be part of your household.
Please provide an estimate of your household's monthly gross income.*
Please review the definition of household size above
How many people in your household are age 17 and under?*
How many people in your household are between the ages of 18 and 59? *
How many people in your household are age 60 and over?*
By checking the box below I do swear or affirm under the penalties of perjury that the information that I have given in the accompanying application for legal services is full, true and correct to the best of my knowledge, information and belief.*

I affirm that all information provided is true and correct to the best of my knowledge, information, and belief.
By checking the box below I understand I am requesting help, but this does not create a representation agreement & FreeState Justice cannot promise that it will be able to place my case or provide legal assistance.*

I understand that this is a request, and does not create a representation agreement or guarantee legal services.
How would you describe your racial and ethnic identity? (check all that apply)*

I prefer not to answer.Black or African descent - e.g. Jamaican, African American, Nigerian, etc.East Asian - e.g. Chinese, Korean, etc.Indigenous descent - e.g. Navajo Nation, Ojibwe, Nome Eskimo, Quechua, etc.Latine or Hispanic - e.g. Mexican, Puerto Rican, Colombian, etc.Middle Eastern or North African - e.g. Lebanese, Iranian, Syrian, etc.Native Hawaiian or another Pacific Islander - e.g. Samoan, Tongan, etc.South Asian or Desi - e.g. Pakistani, Indian, Nepalese, etc.Southeast Asian - e.g. Thai, Vietnamese, Filipino, etc.White - e.g. European American, German, English, etc.Other
How would you describe your gender identity (check all that apply)*

I prefer not to answerNonbinaryTwo-spiritManWomanQuestioningOther
Do you identify as transgender?*

I prefer not to answerYesNoUnsure
How would you describe your sexual identity (check all that apply)*

I prefer not to answerAsexualBisexualGayLesbianQueerQuestioningStraight/HeterosexualOther
Should be Empty:

This Form Has Moved!

DO NOT SUBMIT THIS FORM!