Heirs Property Referral

Form
Date

MonthDayYear
Today's Date
Legal Assistance - Referral for Services

100 North Laura Street, Suite 600

Jacksonville, Florida 32202

Telephone: (904) 351-0008
CLIENT CONTACT INFORMATION
Name*

First NameLast Name
Client Phone Number*

Area CodePhone Number
Client Email
example@example.com
Client Current Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Best Time To Contact

Hour Minutes

AM/PM Option
Client Date of Birth

MonthDayYear
DOB
Referring Agency
Case Manager Name

First NameLast Name
Case Manager Phone

Area CodePhone Number
Case Manager Email
example@example.com
Release of Information. I hereby authorize a representative of Three Rivers Legal Services to Release information to LISC Jacksonville regarding my contact with Three Rivers Legal Services, the outcome of my case, and the resolution of my referral for services.
Date

MonthDayYear
Today's Date
LISC ELIGIBLE LEGAL AID NEEDS
SELECT THE LEGAL ISSUE(S) WITH WHICH YOU WOULD LIKE ASSISTANCE

A. Answer questions about my legal rightsB. Answer questions about legal process and procedureC. Probate of a deceased relative's estateD. Advance Planning (Will, Power Of Attorney, etc)E. Quieting TitleF. Property TaxesG. Debt CollectionH. Consumer Issues (Mortgage Issues/Refinancing/Liens)I. Housing Remains/Code Violations/Condemned PropertyJ. Foreclosure DefenseK. BankruptcyL. Insurance Coverage Education and OutreachOther
CITIZENSHIP VERIFICATION
I hereby certify that I am a citizen of the United States of America.
Date

MonthDayYear
Today's Date
Should be Empty:

Form

CLIENT CONTACT INFORMATION

LISC ELIGIBLE LEGAL AID NEEDS

CITIZENSHIP VERIFICATION