• Set Aside Clinic Application

  • Legal Eligibility (Nebraska Revised Statute 29-2264)

  • Contact Information

  • Citizenship: I am a...*
  • Is this a safe address to receive mail?
  • Is this a safe email for Legal Aid to use?
  • Format: (000) 000-0000.
  • May we text you on this phone?

  • Demographic Information

  • Gender*
  • Preferred Pronouns
  • Ethnicity*
  • Are you eligible or enrolled in a Native American tribe?*
  • Do you need an interpreter?*
  • Have you ever served in the military, including the Reserves, National Guard, Army, Navy, Air Force, Marines, or Coast Guard?*
  • Has anyone in your household ever served in the military?
  • Do you have a physical disability or cognitive impairment?*
  • Are you a victim of abuse?*

  • Household and Financial Information

  • What is your marital status?*
  • Do you have income from employment?*
  • Does anyone else in your household have income from employment?
  • Do you or anyone in your household have any other income from employment?
  • Type of Income (select all that apply)
  • Do you expect your income to change within the next 90 days?

  • Household and Financial Information (continued)

  • Do you have any checking accounts?*
  • Do you have any savings accounts?*
  • Do you have another type of bank account, such as a Certificate of Deposit (COD)?*
  • Do you or anyone in your household own a vehicle used daily for transportation?*
  • Do you or anyone in your household own any additional vehicles?*
  • Do you or anyone in your household own any real estate (suchas a house or land)?*
  • Do you or anyone in your household have a retirement accountsuch as an IRA/401k/403b?*
  • What is your housing situation?*
  • Are you at risk of losing your housing?

  • Case Information

  • Do you have any pending criminal charges anywhere in the US?*
  • Are you on probation or parole?*
  • Have you been convicted of any criminal or traffic offenses in the past two (2) years?*
  • Are you required to register as a sex offender?*
  • Have you been denied employment, housing or other opportunities due to your Nebraska criminal history?*
  • Are you requesting to set aside a conviction related to domestic violence or child abuse and neglect?*
  • Have you been denied opportunities due to criminal charges (not convictions) that were dismissed or where you were found not guilty (acquitted)?*
  • Do you have a conviction that occurred because you were experiencing sex trafficking?*
  • Should be Empty: