Application for J6 Family Financial Assistance

Application for J6 Family Financial Assistance

Financial Assistance for Eligible Individuals and Households
Defendant Information

Please fill out this section completely.
Defendant Name *

First NameLast Name
Defendant Date of Birth *

MonthDayYear
Case Number *
Arrest Date *

MonthDayYear
Defendant Bond Status *
Detained/Home Incarceration/Home Detention/Personal Recognizance
Does the defendant have a criminal history? *

YesNo
If yes to the above question, on a scale of 1-10 how significant is the criminal history (ten being the most significant)?
This information will help us determine which lawyer to connect you with
If Defendant is DETAINED, Please Provide Name of Holding Facility and Address

Holding Facility

Street

CityState / Province

Postal / Zip Code
If Defendant is NOT Detained, Please Provide Defendant Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
If Defendant is NOT Detained, Briefly Describe Release Conditions
Optional
Check box that best describes what you are applying for *

LegalFamily
Defendant Current Job & Income Information (Section A)

Please fill out this section to the best of your knowledge EVEN if defendant is detained or under conditions of home incarceration. If defendant has recently experienced job loss SPECIFICALLY due to facing charges relating to January 6, please fill in with most recent employment information.
Defendant Employment Information *

EmployedSelf Employed (Skip to Section B)Not Employed (Skip to Section C)Other
Current Job 1

Employer Name

Street Address (Optional)

CityState / Province

Postal / Zip Code
Current Job 1 Phone Number
Please enter a valid phone number.

Current Job 1 Income Information

	Wages/Tips (before taxes)	Hourly	Monthly	Yearly	Average Hours Worked Each Week
$

Upload proof of income (Paystub, unemployment letter, VA letter etc.)

Upload Files
Cancelof
Other information regarding your employment:
Defendant Current Job & Income Information (Section B)

Please fill out this section if defendant is Self-Employed.
(Part 1) Type of Work

Self-Employment Income

	How much net income (profits after business expenses are paid) will you get from self-employment this month?	Average hours worked each week
$

Upload your most recent 1099, W2 or employment statement:

Cancelof
Other Means of Income Received by Defendant (Section C)

Fill in all that apply.

	Select if Yes	Select if No	Dollar Amount	How Often?	Notes/Comments (Optional)
Unemployment
SNAP/Food Stamps
Alimony
Child Support
Social Security
Retirement
Other (specify in "notes" text box)

Recent Changes to Defendant Employment Status

Please fill out this section if defendant experienced changes to employment status SPECIFICALLY due to facing charges relating to January 6
In the past year, did defendant:

Stop WorkingStarted Working Fewer HoursTerminated/Laid OffNone of TheseOther
Date of Employment Change (if any)

MonthDayYear
Date
Was the change in employment due to the defendant facing charges related to January 6th?

YesNo
If no, use this section to specify reason for change in employment
Applicant Information/Your Information

Please fill out this section completely if you are not the defendant
Your Name *

First NameLast Name
Date of Birth *

MonthDayYear
Relationship to Defendant *
Self/Spouse/Parent/Child/Sibling/Other (specify if other)
Do you live at the same address as the defendant? *

YesNo
If no, please provide your mailing address.

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number *
Please enter a valid phone number.
Second Phone Number
Please enter a valid phone number.
Email *
example@example.com
Applicant/Your Job & Income Information (Section A)

If you have recently experienced job loss SPECIFICALLY due to events surrounding January 6, please fill in with most recent employment information. You do not need to fill out this section if you are the defendant.
If same as above check here.

Job/Income Information is the same as above
Are you employed, self-employed, or not employed?

EmployedSelf Employed (Skip to Section B)Not Employed (Skip to Section C)Other
Current Job 1

Employer Name

Street Address (Optional)

CityState / Province

Postal / Zip Code
Current Job 1 Phone Number
Please enter a valid phone number.

Current Job 1 Income Information

	Wages/Tips (before taxes)	Hourly	Monthly	Yearly	Average Hours Worked Each Week
$

Upload proof of income (Paystub, unemployment letter, VA letter etc.)

Upload Files
Cancelof
Other information regarding your employment:
Your Current Job & Income Information (Section B)

Please fill out this section if you are Self-Employed. You do not need to fill out this section if you are the defendant.
If same as above check here.

Job/Income Information is the same as above
(Part 1) Type of Work

Self-Employment Income

	How much net income (profits after business expenses are paid) will you get from self-employment this month?	Average hours worked each week
$

Upload proof of income (Paystub, unemployment letter, VA letter etc.)

Upload Files
Cancelof
Other information regarding your employment:
Other Means of Income Received by Applicant (Section C)

Fill in all that apply. You do not need to fill out this section if you are the defendant.

	Select if Yes	Select if No	Dollar Amount	How Often?	Notes/Comments (Optional)
Unemployment
SNAP/Food Stamps
Alimony
Child Support
Social Security
Retirement
Other (specify in "notes" text box)

Upload any proofs of income for the above (Paystub, unemployment letter, VA letter etc.)

Upload Files
Cancelof
If the same as above check here.

Job/Income Information is the same as above
In the past year, did you:

Stop WorkingStarted Working Fewer HoursTerminated/Laid OffNone of TheseOther
Date of Employment Change (if any)

MonthDayYear
Date
Was the change in employment due to your loved one/the defendant facing charges related to January 6th?

YesNo
If no, use this section to specify reason for change in employment
Family Information

List family members in defendant's household, including defendant and/or yourself. "Family" includes people related by birth, marriage or adoption who live together.

Defendant Family Information

	First and Last Name	Date of Birth	Relationship to Defendant	If 18 yrs/older: Employer name or source of incomeVery Satisfied	18 yrs/older: Monthly income (before taxes)
1
2
3
4
5
6

General Financial Information

Fill out the corresponding sections that best describes your situation. DO NOT include legal fees in this section - ONLY household bills.
What is the total monthly mortgage/rent? *
Upload most recent Mortgage Statement/Rent Receipt *

Cancelof
What is the total of your monthly utility expenses (electric, gas, water, internet, phone etc.)? *
We may request upon further observation one or more of your utility bills
What is the approximate TOTAL of all monthly household expenses? (mortgage, utilities, food, other items not listed) *

Other Monthly Expenses not Listed Above

	Item/Expense	Monthly $ Amount
1
2
3
4

Total family income for the last three (3) months *
Do you receive income from any other source(s), support, sponsorship, etc.? *

YesNo
What is the total of support/other income you receive per month?
Other Circumstances

In the Space below (or typed on a separate page, or in an email), please describe any other reasons or circumstances that you feel increase your need for financial assistance. (e.g., family circumstances, legal fees, etc.).
Reason or Circumstance:
Signatures
I affirm that the information in this form is true and accurate according to my knowledge.
Signature *
Date *

MonthDayYear
Should be Empty:

Application for J6 Family Financial Assistance

Defendant Information

Defendant Current Job & Income Information (Section A)

Defendant Current Job & Income Information (Section B)

Other Means of Income Received by Defendant (Section C)

Recent Changes to Defendant Employment Status

Applicant Information/Your Information

Applicant/Your Job & Income Information (Section A)

Your Current Job & Income Information (Section B)

Other Means of Income Received by Applicant (Section C)

Family Information

General Financial Information

Other Circumstances

Signatures