Affidavit Of Eligibility and Verification

Affidavit Of Eligibility & Verification
Email*
example@example.com
Your Legal Name*

First NameLast Name
Your Organization's Name (if relevant)
Are you applying on behalf of yourself (individual), a group, a for-profit business, or a nonprofit organization?*

Individual, Group or For-Profit Business Entity (like an LLC)Nonprofit Organization

Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Most recent FY operating budget*
Please see this link to access the table referenced below.
I hereby certify that, to the best of my knowledge, the organization has no practical means of obtaining funds to retain private counsel, and (please check all that apply):*

has a Board of Directors or a membership that is primarily composed of persons that are at or below the income guidelines in the MLSC Family Income Limits table.provides services to persons that are at or below the income guidelines in the MLSC Family Income Limits table.If the above points are not applicable, but you cannot pay market rate legal services, please explain. You may still qualify for assistance.Other

Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Are you applying on behalf of yourself (individual), a group of artists, or a registered for-profit organization?*

IndividualGroupFor-Profit Business Entity (like an LLC)
Family/Household Size

If you are the only person paying for your expenses, you are a family/household of 1. If you are married and share expenses, you are a household of 2. If you have 2 dependent children and no spouse, you are a household of 3.
The number of people in my family who live together as an economic unit or are financially responsible for one another and share expenses.*
Family/Household Gross Annual Income
The gross (before taxes and deductions) income earned (employment) for all members of my family/household – all of whom are financially responsible for one another. (i.e. if you file joint taxes with your spouse, include your joint gross annual income). Provide information that reflects your present circumstances.

$_ /annually*
Family/Household Other Income
Please share any sources of income you might receive. This might include (but is not limited to) Child Support, Alimony, Disability, or Social Security. If not applicable, write "N/A". Provide in the following format: [Type of support]: $_______________/annually *
Family/Household Assets
Please share assets you might own. This might include (but is not limited to) Checking/Savings or Retirement funds. If not applicable, write "N/A". Provide in the following format: [Type of Asset]: $_______________*
Family/Household Debts
Please share debts you might be paying down. This might include (but is not limited to) in Medical, Housing, or Student Loan debt. If not applicable, write "N/A". Provide in the following format: [Type of debt]: $_______________/annually *

Signature*

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Name*

First NameLast Name
Date*

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RecordTypeId
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Affidavit Of Eligibility & Verification

Family/Household Size

Family/Household Gross Annual Income

Family/Household Other Income

Family/Household Assets

Family/Household Debts