Application for Pro Bono/ Modest Means Assistance

Application for the Pro Bono and Modest Means Programs
Name:*

First NameMiddle NameLast Name
Have you gone by any other name (s)?
Maiden, Alias, Etc
Birth Date

MonthDayYear
Date of Birth

MonthDayYear
Date
Phone Number:*
Please only include a phone number that we can reach you at safelyFormat: (000) 000-0000.
E-mail Address:*

Confirmation EmailPlease only include an email where we can safely reach you
Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Marital Status*
Do you identify with a specific gender or sexual orientation?
This answer is not required
Are you a U.S. Citizen?*

YesNo
Explain*
Are you over the age of 60?*

YesNo
Are you under the age of 30?*

YesNo
Are you now or have you ever been associated with the Armed Forces of the USA?*

NoneActive DutyReservesNational GuardMilitary RetireeVeteran
Are you of Hispanic or Latino Origin?*

YesNo
How would you describe you race? Please check all that apply.*

AsianBlack/ African AmericanIndigenous/ Native to the AmericasNative Hawaiian or Other Pacific IslanderMiddle Eastern or North AfricanWhite
Are you currently living through family violence?*

YesNo
Are you a survivor of family violence?*

YesNo
Are you a person living with a disability?*

YesNo
Jurisdiction of your matter*
Case Number, if applicable
Do you have any upcoming court dates? When?*
I am seeking an attorney in the following area*
Brief description of your legal matter - why do you need legal assistance?*
Have you already consulted with an attorney about this matter?*

YesNo
If so, what is the attorney's name?*
Name of opposing party?*
If opposing party is represented by an attorney, what is the attorney's name?
Do you rent or own the home in which you are living?
How much do you pay in rent/mortgage per month?
How many adults, related and non-related, live in your household INCLUDING you?*
Number of Children (related and non-related) living in Household*
Are there children living in the home?

YesNo
Do you and your spouse live in the same household?

YesNo
Do you own any additional property, either land or a home, aside from the one in which you are living?

YesNo
Do you own a business?*

YesNo
If you answered yes, what is the approximate valuation of the land/house?
Please list the make, model, year and approximate value of any vehicles owned
Are you currently employed?*

YesNo
Gross wages per month*
Do you receive any child support or spousal support?

YesNo
If so, how much support?
Do you receive any veteran's benefit?

YesNo
If so, how much veteran's benefit?
Do you receive any public benefits or additional assistance?

SNAPWICTANFFood StampsSSISSDIUnemploymentOtherNone
Medical expenses per month
Childcare expenses per month
Child and/or Spousal Support paid by you
Total Gross Income Per Month
Total Expenses Per Month
Checking Account Balance
Savings Account Balance
Please verify that you are human*
By clicking submit, I certify that all the information provided is true and correct to the best of my knowledge. I understand and agree that if I provide inaccurate, incomplete, misleading, or false information on the application or to The Justice Center, I may be disqualified from participation in any and all Bar Association programs including the Lawyer Referral Service and The Justice Center's Pro Bono (free) and Modest Means (reduced cost) Programs.
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Application for the Pro Bono and Modest Means Programs