FreeState Service Request Form

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.
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