| Date Of Application | _________________________ |
| 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, ? | _________________________ |
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: | _________________________ |
| Food Stamps Amount | _________________________ |
| Unemployment benefits Amount | _________________________ |
| Welfare Amount | _________________________ |
| SSI 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 | _________________________ |