ATTORNEY GRANT PRESCREEN

1
Name* This field is required.WHAT IS YOUR FIRST AND LAST NAME?
First Name
Last Name
2
Email* This field is required.WHAT IS YOUR EMAIL ADDRESS?
example@example.com
3
What School District Do You Live In?* This field is required.PLEASE SELECT FROM THE DROP DOWN MENU. IF YOU LIVE IN WESTCHESTER COUNTY, NEW YORK, PLEASE SELECT "WESTCHESTER."
Andover
Ansonia
Asford
Avon
Barkhamsted
Berlin
Bethany
Bethel
Bloomfield
Bolton
Bozrah
Branford
Bridgeport
Bristol
Brookfield
Brooklyn
Canaan
Canterbury
Canton
Chaplin
Chesire
Chester
Clinton
Colchester
Colebrook
Columbia
Cornwall
Coventry
Cromwell
Danbury
Darien
Deep River
Derby
East Granby
East Haddam
East Hampton
East Hartford
East Haven
East Lyme
East Windsor
Eastford
Easton
Ellington
Enfield
Essex
Farfield
Farmington
Franklin
Glastonbury
Granby
Greenwich
Griswold
Groton
Guilford
Hamden
Hampton
Hartford
Hartland
Hebron
Kent
Killingly
Lebanon
Ledyard
Lisbon
Litchfield
Madison
Manchester
Mansfield
Marlborough
Meriden
Middletown
Milford
Monroe
Montville
Naugatuck
New Britain
New Canaan
New Fairfield
New Hartford
New Haven
New London
New Milford
Newington
Newtown
Norfold
North Branford
North Canaan
North Haven
North Stonington
Norwalk
Norwich
Old Saybrook
Orange
Oxford
Plainfield
Plainville
Plymouth
Pomfret
Portland
Preston
Putnam
Redding
Region 1
Region 4
Region 5
Region 6
Region 7
Region 8
Region 9
Region 10
Region 11
Region 12
Region 13
Region 14
Region 15
Region 16
Region 17
Region 18
Region 19
Ridgefield
Rocky Hill
Salem
Salisbury
Scotland
Seymour
Sharon
Shelton
Sherman
Simsbury
Somers
South Windsor
Southington
Sprague
Stafford
Stamford
Sterling
Stonington
Stratford
Suffield
The Gilbert School District
The Woodstock Academy Public Schools
Thomaston
Thompson
Tolland
Torrington
Trumbull
Union
Vernon
Voluntown
Wallingford
Waterbury
Waterford
Watertown
West Hartford
West Haven
Westbrook
Weston
Westport
Wethersfield
Willington
Wilton
Winchester
Windham
Windsor Locks
Windsor
Wolcott
Woodbridge
Woodstock
WESTCHESTER COUNTY, NEW YORK
4
What was your last reported adjusted gross income?* This field is required.Please enter data from your most recent tax return. You will be required to submit proof of income in the next step of the application process. If you do not file taxes, please select "Not Applicable/No Reported income."
$10,000 or below
$10,000-$20,000
$20,000-$30,000
$30,000-$40,000
$40,000-$50,000
$50,000-$60,000
$60,000-$70,000
$70,000-$80,000
$80,000-$90,000
$90,000-100,000
$100,000-$110,000
$110,000-$120,000
Not Applicable/No Reported Income
More than $120,000
5
How Many People Live In Your Household?* This field is required.Including dependents listed on your most recent tax return.
2
3
4
5
6
7
8
More than 8
6
Does Your Child Have a CURRENT IEP (Individualized Education Plan)?* This field is required.A CURRENT IEP is a requirement of this program. By "current," the IEP should be VALID FOR THE CURRENT SCHOOL YEAR. You will be required to produce your student's CURRENT IEP PLAN in the next step of the process. If you had an IEP several years ago and it was removed or withdrawn for any reason, you must answer NO to this question. If your child has a 504 Plan, you must answer NO and you may submit a prescreening request for the Advocate Grant Program instead.
YESNO
7
How old is the child for whom you are seeking this grant?* This field is required.
Please Select
Please Select
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19-22
8
Have you received a S.E.L.F. grant FOR AN ATTORNEY for THIS CHILD?* This field is required.If you have received an ADVOCATE grant but not an ATTORNEY/ Legal Assistance Program grant, answer NO. IF YOU HAVE ALREADY RECEIVED AN ATTORNEY GRANT FOR THIS STUDENT, YOU ARE NOT ELIGIBLE TO APPLY and must answer YES. (IF YOU HAVE RECEIVED AN ATTORNEY GRANT FOR A DIFFERENT CHILD, YOU ARE ELIGIBLE TO APPLY FOR A NEW CHILD.)
YESNO
9
Have you received a S.E.L.F. grant FOR AN ADVOCATE for THIS CHILD within the last three months?
YESNO
10
Please summarize your child's current legal situation and the goals you wish to achieve for your student. DO NOT RESPOND "I CANNOT AFFORD AN ATTORNEY."* This field is required.
0/100
Huge
Large
Normal
Small
Ok
Ok
11
By signing below, you certify that the answers you have provided in the preceding questions are CORRECT and ACCURATE to the best of your knowledge.
Clear
12
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