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- Do you have any pending criminal charges anywhere in the US? (If yes, you are not eligible to participate in the clinic to SET ASIDE a conviction and may stop the application unless your case is eligible for record sealing.)*
- Are you on probation or parole? (If yes, you are not eligible to participate in the clinic to SET ASIDE a conviction and may stop the application unless your case is eligible for record sealing.)*
- Have you been convicted of any criminal or traffic offenses in the past two (2) years (including speeding, driving under suspension, fail to yield, etc.?) (If yes, you are not eligible to participate in the clinic to SET ASIDE a conviction and may stop the application unless your case is eligible for record sealing.)*
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- Are you required to register as a sex offender?*
- Have you been denied employment, professional licensure, housing, or other opportunities because of your criminal history record?*
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- Are you requesting to set aside a conviction related to domestic violence or child abuse and neglect?*
- Do you have criminal charges (not convictions) on your record that were dismissed, or cases where you were found not guilty (acquitted)?*
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- Do you have a conviction that occurred because you were experiencing sex trafficking?*
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- Gender*
- Pronouns
- Ethnicity*
- Are you eligible or enrolled in a Native American tribe?*
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- Do you need an interpreter?*
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- Do you have a physical disability or cognitive impairment?*
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- What is your marital status?*
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- Do you have income from employment?*
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- Does anyone else in your household have income from employment?*
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- Do you or anyone in your household have any other income from employment?
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- Is your primary source of income from any of the following sources? Social Security payments; DHHS cash benefits; Alimony or child support payments; Student loans; Unemployment and worker's compensation payments; Veterans benefits; Military family allotments; Pension / retirement benefits; Regular insurance or annuity payments; or Income from dividends, interest, rents, royalties or from estates and trusts *
- Do you currently receive any of these additional source(s) of income? Please select all that apply.*
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- Do you expect your income to change within the next 90 days?*
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- Do any members of your household have any of the following expenses? Child support or alimony, Education (including student loan interest), Healthcare debt, Healthcare treatment, Credit card debt, Other debt (loan or line of credit). Please include all monthly expenses that apply.*
- Do you have any checking accounts?*
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- Do you have any savings accounts?*
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- Do you or anyone in your household own a vehicle used for transportation?*
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- Do you or anyone in your household own any additional vehicles?*
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- Do you or anyone in your household own any real estate (such as a house or land)?*
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- Do you or anyone in your household have a retirement accountsuch as an IRA/401k/403b?*
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- What is your housing situation?*
- Are you at risk of losing your housing?
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- Should be Empty: