Legal Aid of Wyoming ARPA Application

Address Information
Address*

Street Address

Apartment Number

CityState / Province

Postal / Zip Code
Are you receiving public assistance benefits? (SNAP, Medicare, SSI, etc.)*

YesNo
Number of People in Household*

Are you currently employed?*

YesNo
Most Recent Employer Information*

Employer Name

Street Address

CityState / Province

Postal / Zip Code
Most Recent Employer Phone*
Please enter a valid phone number.
How many hours per week do you work? *
What is your rate of pay?*
How often are you paid?*

WeeklyBi-WeeklyMonthlyAnnualOther
Gross Monthly Income
Self (wages, salary, commission)*
Enter in the dollar amount.
Spouse/Partner, Other Household Members, Parents (if same household)*
Enter in the dollar amount.
Unemployment Benefits*
Enter in the dollar amount.
Social Security/Retirement Funds*
Enter in the dollar amount.
Maintenance/Alimony*
Enter in the dollar amount.
Other Income*
Enter in the dollar amount.
Total Income

Additional Financial Information
Cash on Hand*
Cash you are carrying, stored at home, etc. Enter in a dollar amount.
Stocks, Bonds, or other Investments*
Enter in a dollar amount.
House(s) or other Property Estimated Value*
Enter in a dollar amount.
Vehicles Owned Estimated Value*
Enter in a dollar amount.

If you need to make any changes to your application you can press Back to make these changes.

If you don't need to make changes, clicking Next will direct you to the final page.

Complete and Sign
Attestation

I certify, attest, and affirm under penalty of perjury that the information I have submitted in connection with this application for legal assistance is complete and accurate to the best of my knowledge and belief. I authorize Legal Aid of Wyoming to verify and investigate the information I provided with my full cooperation at any time. I understand that providing false or misleading statements or omissions to Legal Aid of Wyoming on this application for legal assistance may result in federal, state, and local criminal and civil actions for fines, penalties, damages or imprisonment. I understand that by completing this application for legal assistance that I am not creating a client-attorney relationship with Legal Aid of Wyoming.
Signature*

Clear
Print Name*
Date*

MonthDayYear
MM-DD-YYYY

We're sorry but for this specific project Legal Aid of Wyoming can only serve Laramie County residents.

Please call Legal Aid of Wyoming's Hotline at 1-877-432-9955 to see if you qualify for our other services.

We're sorry but for this specific project Legal Aid of Wyoming can only serve legal those seeking assistance in specific types of fees.

Please call Legal Aid of Wyoming's Hotline at 1-877-432-9955 to see if you qualify for our other services.

We're sorry but for this specific project Legal Aid of Wyoming can only serve legal residents of the United States.

Please call Legal Aid of Wyoming's Hotline at 1-877-432-9955 to see if you qualify for our other services.
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Legal Aid of Wyoming, Inc.