LEGAL AID PRESCREEN

1
Name* This field is required.WHAT IS YOUR FIRST AND LAST NAME?
First Name
Last Name
2
Email* This field is required.WHAT IS YOUR EMAIL ADDRESS?
example@example.com
3
What School District Do You Live In?* This field is required.PLEASE SELECT FROM THE DROP DOWN MENU.
Andover
Ansonia
Asford
Avon
Barkhamsted
Berlin
Bethany
Bethel
Bloomfield
Bolton
Bozrah
Branford
Bridgeport
Bristol
Brookfield
Brooklyn
Canaan
Canterbury
Canton
Chaplin
Chesire
Chester
Clinton
Colchester
Colebrook
Columbia
Cornwall
Coventry
Cromwell
Danbury
Darien
Deep River
Derby
East Granby
East Haddam
East Hampton
East Hartford
East Haven
East Lyme
East Windsor
Eastford
Easton
Ellington
Enfield
Essex
Farfield
Farmington
Franklin
Glastonbury
Granby
Greenwich
Griswold
Groton
Guilford
Hamden
Hampton
Hartford
Hartland
Hebron
Kent
Killingly
Lebanon
Ledyard
Lisbon
Litchfield
Madison
Manchester
Mansfield
Marlborough
Meriden
Middletown
Milford
Monroe
Montville
Naugatuck
New Britain
New Canaan
New Fairfield
New Hartford
New Haven
New London
New Milford
Newington
Newtown
Norfold
North Branford
North Canaan
North Haven
North Stonington
Norwalk
Norwich
Old Saybrook
Orange
Oxford
Plainfield
Plainville
Plymouth
Pomfret
Portland
Preston
Putnam
Redding
Region 1
Region 4
Region 5
Region 6
Region 7
Region 8
Region 9
Region 10
Region 11
Region 12
Region 13
Region 14
Region 15
Region 16
Region 17
Region 18
Region 19
Ridgefield
Rocky Hill
Salem
Salisbury
Scotland
Seymour
Sharon
Shelton
Sherman
Simsbury
Somers
South Windsor
Southington
Sprague
Stafford
Stamford
Sterling
Stonington
Stratford
Suffield
The Gilbert School District
The Woodstock Academy Public Schools
Thomaston
Thompson
Tolland
Torrington
Trumbull
Union
Vernon
Voluntown
Wallingford
Waterbury
Waterford
Watertown
West Hartford
West Haven
Westbrook
Weston
Westport
Wethersfield
Willington
Wilton
Winchester
Windham
Windsor Locks
Windsor
Wolcott
Woodbridge
Woodstock
4
How old is the child for whom you are seeking this grant?* This field is required.
Please Select
Please Select
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19-22
5
S.E.L.F. Legal Aid applicants must have income below 125% of the Federal Minimum Poverty Level (FMPL). Please select the box below that aligns most closely with your family size and income level. IF YOUR INCOME EXCEEDS THE AMOUNT LISTED FOR YOUR FAMILY SIZE, YOU ARE NOT ELIGIBLE.* This field is required.Proof of income (such as 1st 2 pages of income tax return, etc) must be submitted with the S.E.L.F. Legal Aid Application.
Your income is LESS THAN $27,050 AND You are a Family of 2
Your income is LESS THAN $34,150 AND You are a Family of 3
Your income is LESS THAN $41,250 AND You are a Family of 4
Your income is LESS THAN $48,350 AND You are a Family of 5
Your income is LESS THAN $55,450 AND You are a Family of 6
Your income is LESS THAN $62,550 AND You are a Family of 7
Your income is LESS THAN $69,650 AND You are a Family of 8
6
Does Your Child Have a CURRENT IEP (Individualized Education Plan)? IF YOUR ANSWER IS NO, YOU ARE NOT ELIGIBLE.* This field is required.You must submit your student's CURRENT (valid for the current school year) IEP with the application. If you had an IEP several years ago and it was removed or withdrawn for any reason, you must answer NO. If your student's IEP is in process or you only have a 504 Plan, you must answer NO.
YESNO
7
Have you received a S.E.L.F. ATTORNEY GRANT for THIS CHILD? IF YOUR ANSWER IS YES, YOU ARE NOT ELIGIBLE.* This field is required.If you have received an ADVOCATE grant but not an ATTORNEY/ Legal Assistance Program grant, answer NO. IF YOU HAVE RECEIVED AN ATTORNEY GRANT FOR A DIFFERENT CHILD, YOU ARE ELIGIBLE.
YESNO
8
Have you received a S.E.L.F. grant FOR AN ADVOCATE for THIS CHILD within the last three months? IF YOUR ANSWER IS YES, YOU ARE NOT ELIGIBLE.* This field is required.
YESNO
9
Please summarize your child's current legal situation and the goals you wish to achieve for your student. DO NOT RESPOND "I CANNOT AFFORD AN ATTORNEY."* This field is required.
0/100
Huge
Large
Normal
Small
Ok
Ok
10
By signing below, you certify that the answers you have provided in the preceding questions are CORRECT and ACCURATE to the best of your knowledge.
Should be Empty: