Pro Bono Application Intake Form 09232024

Southern Indiana Pro Bono Referrals, Inc.

Application Form
To apply you must return the attached forms and requested information:

1. Application Form - Information provided will be held confidentially.
2. Proof of Income, you need to provide proof of your household income.
3. Court orders, rulings, or notifications handed down in your case, including child support worksheets, if any.
4. Memorandum of Understanding - signed granting permission to release your information to a volunteer attorney or designated legal aid referral.
5. A copy of your valid Driver License or State ID.
6. Guidelines signed acknowledging you understand the limitations of this program.

NOTE:

1) You must notify us of any change in household income.
2) Current contact information is vital. Unsuccessful attempts to contact you will result in a rejection of your application. Email addresses are help.
3) We are a referral program only. We cannot respond to emergencies because it can take weeks to process your application. Much depends on receiving the required and/or requested information.
4) Volunteer attorneys take cases without pay at their discretion and their time must be respected or withdrawals may occur.

If you have any questions please call 812-288-8002.

Sincerely,

Southern Indiana Pro Bono Referrals

Southern Indiana Pro Bono Referrals

Please note: we are a referral program only if there is a legal remedy for your problem, and a volunteer attorney is willing to accept your case

Assets:
OwnRentOther
Monthly Mortgage Rent*
Monthly Mortgage Utilities*
Bank Account Balance*
Savings Account Balance*
Year/Model of Vehicle(s) and their value:*
401(k) and/or Retirement Accounts (name & balances):*

Household Members:
Number of Adults residing in your home:*
Name*
Relationship*
Age*
Date of Birth*

MonthDayYear
Date
Monthly Income*
Income Source*
Name*
Relationship*
Age*
Date of Birth*

MonthDayYear
Date
Monthly Income*
Income Source*
Name*
Relationship*
Age*
Date of Birth*

MonthDayYear
Date
Monthly Income*
Income Source*
Name*
Relationship*
Age*
Date of Birth*

MonthDayYear
Date
Monthly Income*
Income Source*
Name*
Relationship*
Age*
Date of Birth*

MonthDayYear
Date
Monthly Income*
Income Source*
Number of Children residing in your home full-time (under 19):*
First Child's Name*
Relationship*
Age*
Date of Birth*

MonthDayYear
Date
Second Child's Name*
Relationship*
Age*
Date of Birth*

MonthDayYear
Date
Third Child's Name*
Relationship*
Age*
Date of Birth*

MonthDayYear
Date
Fourth Child's Name*
Relationship*
Age*
Date of Birth*

MonthDayYear
Date
Fifth Child's Name*
Relationship*
Age*
Date of Birth*

MonthDayYear
Date
Sixth Child's Name*
Relationship*
Age*
Date of Birth*

MonthDayYear
Date
Seventh Child's Name*
Relationship*
Age*
Date of Birth*

MonthDayYear
Date
Eighth Child's Name*
Relationship*
Age*
Date of Birth*

MonthDayYear
Date
Ninth Child's Name*
Relationship*
Age*
Date of Birth*

MonthDayYear
Date
Tenth Child's Name*
Relationship*
Age*
Date of Birth*

MonthDayYear
Date

Opposing Party Information:
Name*

First NameLast Name
Prior Names
Date Birth? If known*

MonthDayYear
Date
Relationship to you*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Telephone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Cell Number*
Please enter a valid phone number.Format: (000) 000-0000.
Work Number
Please enter a valid phone number.Format: (000) 000-0000.
YesNoDon't Know
YesNo
Name of Attorney*

What is your problem?*
Who is involved?*
What do you want us to do for you?*

Retainer Agreement for Clients through Pro Bono Indiana, Inc.

I, {name}, am requesting a referral to a volunteer attorney through the Southern Indiana Pro Bono Referrals (SI-PBR) for representation in the following matter:

{matter}

Pro Bono Indiana, Inc. and Volunteer Private Attorney agree to assist the above-named Client, with their above-named Legal Issue, under the following circumstances:

- Representation will be limited to this matter only and does not include any other legal issues or any appeal of this matter. The representation will end upon completion of the above matter or as noted below.

- I will not be charged attorney’s fees for the services provided to me under this agreement.

- If, because of the nature of the legal matter that is the subject of this agreement, my attorney is able to collect attorney’s fees from the adverse party, my attorney is hereby authorized to keep such fees.

- The above-described representation is limited to the period during which my income is less than that prescribed by Federal Poverty Level Guidelines and the income/asset guidelines used by the local office of Pro Bono Indiana, Inc.

- That if, at any time, my assets or income exceed those limits, I will be ineligible for further free representation.

- That in such instance, I may choose to continue my representation with my attorney on a fee-for- service basis or will be entitled to a copy of all papers in my file.

- There may be filing fees and other costs and agree to pay all such costs unless they are waived by the court.

- Other expenses, such as fees for depositions, expert witnesses, transcripts and consultants may be necessary during the presentation of my case.

- That my attorney will consult with me and obtain my approval, or the approval of Pro Bono Indiana, Inc. before authorizing such expenditures.

- To be fully responsible for any expense which I approve, unless other specific arrangements are made in writing with my attorney or Pro Bono Indiana, Inc.

- That my attorney will consult with me and obtain my approval before taking major steps in handling my case, including filing of any lawsuit.

- That it is my responsibility to cooperate fully with my attorney, including disclosing all relevant information and not making any material misrepresentations.

- That, if I breach these agreements, my attorney may cease to represent me.

- That, if I do not remain in contact with my attorney, my attorney may cease to represent me.

- That, my attorney’s obligations under this agreement will end when otherwise required or allowed by the Rules of Professional Conduct.

- To remain in contact with my attorney at all points during my representation and agree to notify my attorney immediately of any change in my current mailing address, phone number, or any change of income. ________
Client Signature for Acceptance of Retainer Agreement*

Powered by Jotform SignClear
Client Name Print*

First NameLast Name
Today's Date

MonthDayYear
Date

SI-PBR Guidelines
Please Read Carefully

APPLICATION

This application must be filled out accurately and completely to determine if you qualify for our services.

We will consider many factors, including your income and whether your legal issue actually requires the assistance of an attorney by examining the merits of your case among other factors.

If you qualify, we will notify you that your case has been accepted and the search for a volunteer pro bono (free) attorney has begun. We cannot guarantee that an attorney will volunteer. If no volunteer has come forward within 90 days, you will be notified that your application may be closed. In the meantime, should you decide you do not need a volunteer attorney, please notify our office immediately.

RELEASE OF INFORMATION

In order to refer your case to a volunteer attorney, some of your information needs to be shared with a potential volunteer to do a conflict check. Once a volunteer has determined that there is no conflict and accepts your case, all the information you have provided will be forwarded to the volunteer. By applying for our services in seeking a volunteer attorney, you agree to the release of your information to an attorney as necessary.

ATTORNEY FEES

If you are eligible for a referral, your assigned attorney will represent you pro bono (without charge) unless the court orders the other party to pay your attorney fees. If the court orders the other party to pay your attorney fees, the volunteer may demand and retain such fees or donate those fees to Southern Indiana Pro Bono Referrals.

COPIES OF DOCUMENTS

Do not provide originals to our office as any documents you will not be returned to you. Copies provided to us will remain in your file whether we are able to provide you with services or not. Be assured all your information will be kept confidentially.

CLIENT RESPONSIBILITIES

Filing Fees and Costs: The court may, but not always, waive filing fees for individuals who qualify financially for our services. A notable exception is the bankruptcy petition filing fee which is rarely waived. In the event the fees in your case cannot be waived, you will need to pay the appropriate filing fee up front.

Volunteer attorneys who to accept cases without charging fees for their work are not agreeing to pay out of their own pocket for the court costs or expenses in your case. You are ultimately responsible for all costs and expenses of your case. Should you be assigned to a volunteer attorney, you must discuss such fees and expenses with the volunteer attorney at your first meeting about potential costs that may arise in your case.

COOPERATION WITH YOUR PRO BONO ATTORNEY

An attorney referred to you is strictly a volunteer and is not obligated by rule of law to represent you without charge. The attorney has agreed to provide you with a consultation. After the consultation the volunteer with decide whether to accept your case or not. The volunteer attorney is not employed by or otherwise associated with this Pro Bono Referral Program.

You must cooperate with your attorney in developing your case by keeping all scheduled appointments and being prompt, courteous and prepared. Do not bring your children to meetings with your attorney.

Do not post anything about your case to any “social media” sites or send any information about your case by texting or e-mail, etc. (except to your attorney, since that is privileged information). Such “postings”, texts and e-mails can be subpoenaed directly from the social media sights. You could damage your case and force your “friend” to become a witness to discuss all the conversations they have ever had with you. Please take this warning seriously.

When your case is completed, your attorney will withdraw from further representation and will not appeal a court decision on a pro bono basis.

YOUR CASE WILL BE CLOSED IMMEDIATELY, if:

1. You misrepresent information in your application;
2. You fail to show for scheduled appointments; or
3. You don’t cooperate with your attorney. Failure to cooperate is grounds for the attorney to withdraw from your case making you ineligible for any further assistance by this program.

REPORTING NEW INFORMATION

If you change your address or telephone number, you must notify our office. If we cannot locate you because you moved and/or changed your telephone number and did not notify us, we will have to close your case.

If you are accepted into our Program, while awaiting placement with a pro bono attorney, you must keep our office updated regarding significant developments in your case (i.e. if you are served with a motion or find out something has been scheduled in your case).

While your case is open, you must inform the Pro Bono Program in writing if your income changes from what it was at the time you first applied. If your new income exceeds our guidelines, you will be declared ineligible for pro bono services and your attorney may be permitted to charge his/her normal hourly rate, starting when you became ineligible. We reserve the right to inquire into your financial situation.

I hereby acknowledge that I have read and understand the above policies and have received a copy of the same.
Client Signature Acknowledging Acceptance of SI-PBR Guidelines*

Powered by Jotform SignClear
Client Name Print*

First NameLast Name
Today's Date

MonthDayYear
Date

REQUIRED PROOF OF INCOME

Before SI-BPR can process your application, you must submit your financial information to:
Southern IN Pro Bono Referrals

P.O. Box 94 New Albany, IN 47151

or

EMAIL: SIPBR@PROBONOINDIANA.ORG

Household Income Verification - PLease provide copies of:
- 2 months pay stubs
- Last 2 months bank statements
- Last tax reutnr filed w/all schedules & W2's
- Proof of child support, disability benefits, unemployment, retirement benefits, alimony, maintenance, SSI.
- If you don't have income YOU MUST provide a letter from the person(s) who are paying for your food and giving you a play to stay including their monthly income. If you are in a Shelter a letter from them.
- Copy of your valid Driver License or Stated Identification.
PLEASE BE AWARE THAT YOUR CASE CANNOT BE REVIEWED WITHOUT INCOME VERIFICATION. We will consider your application withdrawn, if you do not submit the requested financial information.

Sincerely,

Soutehrn Indiana Pro Bono Referrals

Soutehrn Indiana Pro Bono Referrals

After you review answers and click submit, scroll up to sign document.
Signature

Powered by Jotform SignClear
Should be Empty:

Southern Indiana Pro Bono Referrals, Inc.

Application Form

INCOME:

Assets:

Household Members:

List of Children that are subject of this case:

Opposing Party Information:

Case Information:

Current Legal Proceedings

DOMESTIC VIOLENCE

Type of Matter:

Retainer Agreement for Clients through Pro Bono Indiana, Inc.

SI-PBR Guidelines

REQUIRED PROOF OF INCOME