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Appellate Clinic for Self Represented Litigants Application
Para ver este formulario en Español, por favor haga clic en el botón de traducción en la esquina superior derecha.
Please read and and fill out this application completely each time you wish to ask for assistance. Until you have filled out and submitted this application we cannot assist you. Thank you.
PLEASE NOTE: This clinic is NOT part of the Court of Appeal. Any communications you have with this clinic ARE NOT communications with the court.
Date
.
Month
.
Day
Year
Date
Are you currently represented by an attorney for your appeal case?
*
Yes
No
You are not eligible for the services of the Appellate Clinic for Self Represented Litigants
Contact Information
Name
*
First
Middle
Last
Address
Street Address
Street Address Line 2
City
State
Zip Code
*
Zip Code
Phone Number 1
*
Phone Number 2
Do you have an email address?
*
Yes
No
E-mail
*
You will receive a copy of this form at this address
Demographic Information
Birthdate
*
mm.dd.yyyy
Gender
*
Woman
Man
Non-binary
Prefer not to answer
Disability
*
Yes
No
Decline
Service Member or Veteran
*
Yes
No
Limited English Fluency?
*
Yes
No
Race / Ethnicity
*
Alaska Native
American Indian
Arab/Middle Eastern/North African/Arab American
Asian
Black/African Diaspora
Hispanic/Latinx
Indigenous
Native Hawaiian or Pacific Islander
White/Caucasian Non-Latinx
Multiple/Mixed Race
Prefer not to answer
Primary Language
*
English
Spanish
Fee Waiver/Income Information
Here, "household" means the people you share income and expenses with.
Have you been granted a fee waiver?
*
Yes
No
How many people are in your household?
*
What is your monthly household income (before taxes and deductions)?
*
You and Your Case
How many lawsuits have you been a party to in the last 5 years?
1 (the one leading to this appeal)
2-5
More than 5
How did you hear about the Appellate Clinic for Self-Represented Litigants?
*
Public Counsel website
Court website
LA County Law Library
Judge
Name of Judge
Case Number(s)
*
Please select one of the following:
*
I am the APPELLANT (I have filed an appeal, or am considering filing an appeal)
I am the RESPONDENT (an appeal has been filed against me)
What do you believe the trial judge did wrong what would entitle you to a reversal of the judgment in your case (check all that apply)
*
The judge would not let me speak
The judge would not give me a continuance
The judge would not look at my evidence
The judge believed obvious lies by the other party
Other
Please describe what the trial judge did wrong that you believe should entitle you to a reversal of the judgment in your case? Please note, if you have visited the clinic before, you can just write "see previous form"
*
0/250
What kind of case is this?
*
Civil Rights
Discrimination
Employment
Eviction
Family (e.g. divorce, child custody)
Foreclosure
Restraining Order
Were you represented by an attorney at any point in this litigation?
*
Yes
No
Attorney name
Attorney phone number
Acknowledgement of Self-Represented Litigant Status
I certify that the above statements are true. 1) I understand that neither Public Counsel nor the attorneys at the Appellate Clinic for Self-Represented Litigants are my attorneys. 2) I understand that I am representing myself in all matters discussed at the clinic and am proceeding on a self-represented basis regarding any matters discussed at the clinic. 3) I acknowledge that there are procedures, time limitations, and deadlines that may apply to any case for which I am seeking assistance and that, as a self-represented litigant, it is my sole responsibility to determine and comply with such requirements. 4) I understand that unless Public Counsel and/or the attorneys at this clinic and I enter into a separate written agreement, Public Counsel and the attorneys at this clinic WILL NOT REPRESENT ME IN ANY MATTER or perform any other service/task.
*
I understand and agree
Signature
Clear
Submit
Should be Empty: