Application for Services

Application For Services
Date Of Application
Last Name
First Name
Middle/Maiden Name
Mailing Address
City
State
Zip Code
Email Address
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 Separated
Spouse Full Name
Separation Date (If Applicable)

Case Information
Opposing Party's Name (if known) Name of person who this case is against or who filed case against you)
Opposing Party's Date of Birth
Opposing Party's Social Security Number
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 is the emergency?

Income Information (Please include all Household income)
Your Employer
Gross Salary, before deductions
Please specify if the amount above is Daily, Weekly, Monthly, Annually or Other.	Daily Weekly Monthly Annually Other
If "Other" please explain:
Spouse's Employer (If living together)
Spouse Gross Salary before deductions
Please specify if the amount above is Daily, Weekly, Monthly, Annually or Other.	Daily Weekly Monthly Annually Other
If "Other" please explain:
Unemployment benefits Amount
Welfare Amount
SSI Amount
Social Security Amount
Veterans Administration Amount
Child Support Amount
Other Income Amount
Checking Account Balance (As of this date)
Savings Account Balance
Vehicle(s) Value (only if more than 1 vehicle)
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 boyfriend/girlfriend	Adults Children

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PLEASE NOTE: IF YOU HAVE AN EMERGENCY, PLEASE CONTACT OUR OFFICE IMMEDIATELY AFTER SUBMITTING YOUR APPLICATION.

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