Application for Services
Please fill out the following completely.
Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
What County do you reside in?
*
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Please select the kind of case you wish to file:
*
Divorce
Guardianship
Power of Attorney
Have you been assisted by Elkhart Legal Aid Services in the past?
*
Yes
No
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?
*
Yes
No
If yes, how much?
Do you receive TANF?
*
Yes
No
If yes, how much?
Please list your expenses
Rent (monthly)
*
Utilities
*
Telephone
*
Miscellaneous
*
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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.
Applicant Information
Name
*
First Name
Last Name
Age
*
Source of Income
*
Amount of Income
*
Resident 1
Name
First Name
Last Name
Relationship to Applicant
Age
Source of Income
Amount of Income
Resident 2
Name
First Name
Last Name
Relationship to Applicant
Age
Source of Income
Amount of Income
Resident 3
Name
First Name
Last Name
Relationship to Applicant
Age
Source of Income
Amount of Income
Resident 4
Name
First Name
Last Name
Relationship to Applicant
Age
Source of Income
Amount of Income
Resident 5
Name
First Name
Last Name
Relationship to Applicant
Age
Source of Income
Amount of Income
Resident 6
Name
First Name
Last Name
Relationship to Applicant
Age
Source of Income
Amount of Income
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Next
If a change of address, telephone number, income, or household composition occurs, I will immediately notify Elkhart Legal Aid Services, INC
Signature
*
Name
*
First Name
Last Name
Continue
Continue
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