Application for Services
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Application Date
Last Name
First Name
Middle/Maiden Name
Mailing Address
City
State
Zip Code
Citizen of U.S.
Yes
No
Parish
Home Phone Number
Work Phone Number
Alternate Phone Number
Social Security Number
Date Of Birth
Sex
Male
Female
Race
Marital Status
Single
Married
Divorced
Spouse Full Name
Separation Date
Case Information
Opposing Party's Name (if known)
Type of legal problem (Ex.--spouse abuse,social security case, bankruptcy, eviction,car loan)
Have You been served with papers?
Yes
No
If so, When?
Has a court hearing date been set?
Yes
No
If so, When?
Is there an emergency?
Yes
No
If so, what?
Income Information
Employer
Spouse Employer
Client Salary (Gross - Wage per hr. x hrs. worked per week)
How Often do you get paid?
Daily
Weekly
Monthly
Other
If "Other" please explain:
Spouse Salary (Gross- wage per hour x hours worked per week)
How often does your spouse get Paid?
Daily
Weekly
Monthly
Other
If "Other" please explain:
Food Stamps Amount
Unemployment benefits Amount
Welfare Amount
SSI Amount
Social Security Amount
Verterans Administration Amount
Child Support Amount
Other Income Amount
Checking Account (Account on date of application)
Name of Checking Account Bank
Savings Account
Name of Savings Account Bank
Car(make and year model)
Home Type (rent, own, or buying)
Rent
Own
Buying
Other Land owned - Not the home(approx. value)
Other Assets
Number of people in the household (include yourself. dependent children and spouse or boyfrind/girlfriend
