Set Aside Clinic Application
This application covers personal information, demographics, case information, and financial information to determine if you are eligible for the clinic. The form may take between 20-30 minutes to complete.
Citizenship: I am a...
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US Citizen
Non-citizen
Full Name
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Prefix
First Name
Middle Name
Last Name
Suffix
Have you gone by any other names, such as a given-name or former name?
Date of Birth
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Last four digits of Social Security Number
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Provide the address where you live. If you are homeless, provide an address where you spend most of your time.
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Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Is this a safe address to receive mail?
Yes
No
Email Address
*
example@example.com
Contact Number
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Please enter a valid phone number.
Format: (000) 000-0000.
May we text you on this phone?
Yes
No
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Demographic Information
Gender
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Male
Female
Prefer not to say
Preferred Pronouns
She/Her
He/Him
They/Them
Other
Ethnicity
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American Indian or Alaskan Native
Asian
Black or African American
Hispanic, Latino, or Spanish
Middle Eastern or North African
Native Hawaiian or Pacific Islander
White/Caucasian
Some other race, ethnicity, or origin
Two or more races
Unknown
Are you eligible or enrolled in a Native American tribe?
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Yes
No
I don't know
If yes, which Tribe?
Please Select
Iowa Tribe of Kansas and Nebraska eligible
Iowa Tribe of Kansas and Nebraska enrolled
Oglala Sioux eligible
Oglala Sioux enrolled
Omaha eligible
Omaha enrolled
Ponca eligible
Ponca enrolled
Rosebud Sioux eligible
Rosebud Sioux enrolled
Sac and Fox eligible
Sac and Fox enrolled
Santee Sioux eligible
Santee Sioux enrolled
Winnebago eligible
Winnebago enrolled
Other tribe eligible
Other tribe enrolled
Do you need an interpreter?
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Yes
No
If yes, which language?
Have you ever served in the military, including the Reserves, National Guard, Army, Navy, Air Force, Marines, or Coast Guard?
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Yes
No
Has anyone in your household ever served in the military?
Yes
No
Do you have a physical disability or cognitive impairment?
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Physical disability (such as mobility, vision, hearing)
Cognitive impairment (such as problems with memory or understanding)
Mental health challenges
Other
None
Are you a victim of abuse?
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Yes
No
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Case Information
Do you have any pending criminal charges anywhere in the US?
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Yes
No
Are you required to register as a sex offender?
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Yes
No
What cases do you want to set aside or sealed?
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In what year(s) did these charges or convictions happen? If you do not know the exact year, please estimate the year(s) approximately and list below.
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Household and Financial Information
What is your marital status?
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Single
Married
Divorced
Widowed
Separated
Group
Domestic Partner
Other
In your household, how many adults are aged 19 or over?
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How many children live in the house full time?
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Do you or anyone in your household have income from employment?
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Yes
No
Hours per week
Wages per hour
Do you or anyone in your household have other employment?
Yes
No
Hours per week
Wages per hour
Do you or any members of your household have income from other sources?
Yes
No
Type of Income (select all that apply)
Social Security (SSI)
Social Security Disability Insurance (SSDI)
Social Security Survivors Benefit
Veteran's Benefits
Pension/Retirement (IRA/401K)
Trust/Interest/Div
Unemployment Insurance
SNAP/WIC/Food stamps
State Stipend
Adoption Stiped
Foster Care Stipend
TANF/ADC
Child Support
Alimony
Student Loans
Workmens Comp
Other General Assistance
Other
How often is this income received?
Weekly
Bi-Weekly
Monthly (12 times per year)
Annually (once per year)
Other
How much is received?
Do you expect your income to change within the next 90 days?
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Yes
No
Assets and Personal Property
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Estimated value of personal property, including bank accounts
Do you have any vehicles you do not use for transportation to work or school?
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Yes
No
Estimated value of vehicles
Do you own any real estate?
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Yes
No
Estimated value of real estate
Do you have a retirement account such as an IRA/401k/403b?
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Yes
No
Estimated value
Do you have a checking account?
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Yes
No
Estimated value
Do you have a savings account or certificate of deposit?
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Yes
No
Estimated value
Do any members of your household have any of the following expenses?
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Child care
Child support or alimony
Education (including student loan interest)
Medical debt
Medical, dental, or mental health care
Credit card debt
Other debt (loan, line of credit)
If yes, please estimate the monthlty total of these expenses:
What is your housing situation?
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Rent: Private landlord
Rent: Public housing
Rent: Housing voucher/subsidized/Section 8
Rent: Other rental assistance (GA, Regional, etc)
Own: Real property
Own: Mobile home
Own: Condo/Townhome/Co-op
Homeless
Other (including assisted living, long-term care)
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Submit
Should be Empty: