Application for Services

Please select the kind of case you wish to file:*

DivorceGuardianshipPower of Attorney
Have you been assisted by Elkhart Legal Aid Services in the past?*

YesNo
If yes, what was your name:
How many people, INCLUDING YOURSELF, reside at the above address?*
What is the total income before taxes for ALL persons working and living at the above address?*
Do you receive SNAP/Food stamps?*

YesNo
If yes, how much?
Do you receive TANF?*

YesNo
If yes, how much?
Please list your expenses
Rent (monthly)*
Utilities*
Telephone*
Miscellaneous*

Complete the following for all persons who reside at the above address

For Source of Income, insert the name of employer or SS, AFDC, Unenmployment, or Workman's Compensation, Child Support, Rental Income, and/or any help (either money or resources you receive from family and/or friends. For Amount of Income, list income BEFORE TAXES, hourly income and number of hours worked per week or indicate whether income is monthly.
- Name*
  
  First NameLast Name
- Age*
- Source of Income*
- Amount of Income*
- Name
  
  First NameLast Name
- Relationship to Applicant
- Age
- Source of Income
- Amount of Income
- Name
  
  First NameLast Name
- Relationship to Applicant
- Age
- Source of Income
- Amount of Income
- Name
  
  First NameLast Name
- Relationship to Applicant
- Age
- Source of Income
- Amount of Income
- Name
  
  First NameLast Name
- Relationship to Applicant
- Age
- Source of Income
- Amount of Income
- Name
  
  First NameLast Name
- Relationship to Applicant
- Age
- Source of Income
- Amount of Income
- Name
  
  First NameLast Name
- Relationship to Applicant
- Age
- Source of Income
- Amount of Income

If a change of address, telephone number, income, or household composition occurs, I will immediately notify Elkhart Legal Aid Services, INC
Signature*

Powered by Jotform SignClear
Name*

First NameLast Name
Should be Empty:

Complete the following for all persons who reside at the above address