PRO BONO UNIT

PRO BONO UNIT

(General Simplified Intake Form & Waiver)
Form updated 7/23/2025 -AJI
Date*

MonthDayYear
Legal Name*

First NameMiddle NameLast Name
Preferred Name (if different from your legal name)

First NameMiddle NameLast Name
Mailing Address*

Street Address (including apartment or unit number)

City

CountyState

Zip Code
Is the above address the same address where you reside?*

YesNo
If not, where do you reside?

Street Address (including apartment or unit number)

City

CountyState

Zip Code
Phone (best number for contact)*
Format: (000) 000-0000.
Can we text you at this number?*

YesNo
Safe and Confidential Email Address
example@example.com
Birth Date*

MonthDayYear
Age*
Last 4 of SSN*
Gender/Gender Identity*
Citizenship Status*
Ethnicity*

HispanicNon-HispanicOther
Race*

Black/African AmericanAsianWhite/CaucasianNative AmericanPacific IslanderUnknownOther
Marital Status*

SingleMarriedPartnered (not married)DivorcedWidowedSeparated (but married)Other
Veteran/Military Status*

Not ApplicableActive DutyReservesMilitary SpouseChild or Sibling of a VeteranRetired/DischargedIf Retired/Discharged, please check the box and list your discharge date.
Have you ever applied to JALA before?*

YesNo
If yes, when?
Income and Asset Verification

**Jacksonville Area Legal Aid uses this information for grant qualifying purposes. This information is not disclosed to anyone except legal aid. Estimated amounts are permissible
Are you currently employed?*

YesNo
If Yes, where are you currently employed?
What is your Gross Monthly Income?*
Income before taxes and other withholdings.
Do you have other sources of income? If so, from where or from whom? *
This includes income from other people residing in your home (e.g. spouse or adult child)
What is the total Gross Monthly Income from this other source?*
Income before taxes and other withholdings.
Total number of adults, including yourself, residing in your home.*
Total number of minors (under 18) residing in your home.*
Real Estate (Primary Residence) Value*
Applicable only if you own (not rent) a home.
Value of Other Real Estate*
If none, enter 0.00
Value of Primary Vehicle*
If none, enter 0.00
Value of Secondary Vehicle*
If none, enter 0.00
Value of Other Vehicles*
Example: other cars, motorcycles, boats. If none, enter 0.00
Monthly Mortgage or Rent Amount*
Include first and second mortgages
Value of Retirement Account*
If none, enter 0.00
Checking Account Value*
If none, enter 0.00
Savings Account Value*
If none, enter 0.00
Value of any other accounts*
If none, enter 0.00
What kind of legal problem do you have?
Consumer

CollectionRepossessionSmall ClaimsUtilitiesWarranty ClaimBankruptcy
Employment

Job LossWorkman's CompWage ClaimUnemploymentDiscrimination
Family

Adoption (adult)Adoption (minor)Divorce with ChildrenDivorce without ChildrenPaternityCustody/VisitationChild SupportRestraining OrderTemporary CustodyName Change
Probate, Guardianship, Estate

Probate of an EstateWill CreationWill DisputeAdvance DirectivesPower of AttorneyGuardianship (adult)Guardianship (minor)
Benefits

Social SecuritySSI/SSDIWagesFood StampsMedicareMedicaidHealth InsuranceMental HealthVeterans
Housing

Landlord/TenantForeclosureHomeowners/Condo AssociationDeed IssuesSquatterDiscrimination in purchasing or renting
Immigration

Visa (for self)Visa (for family)CitizenshipAsylum
Other (not listed above)
Case Number and County (if applicable)
Example: 2025-CC-1234 - Duval County
Adverse Party's Name (if applicable)
Person/Organization with whom there is a dispute with, if any
Briefly Describe Your Legal Problem*

0/500
PARTICIPANT VERIFICATION
By using this form, you agree that the information in this tool is not a substitute for legal advice. Jacksonville Area Legal Aid, Inc. (JALA) will use the information you provide to determine if we are able to help you. JALA is not able to help with every type of legal issue or case matter. Our office prioritizes certain types of cases that fit our mission and our funding sources. COMPLETING THIS APPLICATION DOES NOT MEAN THAT YOU ARE OUR CLIENT OR THAT WE WILL BE ACCEPTING YOUR CASE. Ask-A-Lawyer Type Clinics: I understand that unless a separate Retainer Agreement is signed by me and the attorney/law firm, an attorney who speaks with me is not committing to represent me in any legal matter. I further understand that an attorney will not render a definitive legal opinion concerning my matter, as it may be impossible to fully assess a matter within the timeframe allotted for the discussion and with the limited information or documentation provided. Any legal assistance provided in today's session will be free of charge. The attorney has no obligation to me after our interview and I have no obligation to the attorney. Accordingly, I understand that speaking with an attorney in no way constitutes an attorney-client relationship and neither the attorney(s), the Jacksonville Bar Association, nor Jacksonville Area Legal Aid, Inc., may be referred to as your attorney. The information that I have provided in this form is true and complete.*
PARTICIPANT ACKNOWLEDGEMENT OF SHARING INFORMATION
I acknowledge and agree that any information provided herein can be shared between Jacksonville Area Legal Aid. Inc. and any other legal partners (e.g. referral for placement with an attorney or other legal aid organization). Sharing of information among shall not waive the attorney-client privilege.*
Should be Empty:

Income and Asset Verification

What kind of legal problem do you have?

PARTICIPANT VERIFICATION

PARTICIPANT ACKNOWLEDGEMENT OF SHARING INFORMATION