APPLICATION FOR LEGAL ASSISTANCE UNCOMPAHGRE VOLUNTEER LEGAL AID (UVLA)

APPLICATION FOR LEGAL ASSISTANCE
UNCOMPAHGRE VOLUNTEER LEGAL AID (UVLA)

Return completed application by mail to PO Box 488, Montrose CO 81402, or by email to ic@uvlamontrose.org

Date of Application:

Applicant’s Legal Name:

First Name

Middle Name

Last Name

Applicant’s Mailing Address:

City, State, ZIP

County of Residence

Safe to contact you here?
YesNo

Phone

(H)

(W)

Cell/Other

Your email address:

Safe to email you?
YesNo

Last 4 digits ONLY of Social Security Number:

Date of Birth

Age

Sex:
MaleFemale

Primary Language

Spouse or Partner:

First Name

Middle Name

Last Name

Date of Birth

Are you a Citizen?
YesNo

Are you a permanent resident?
YesNo

Other legal status?
YesNo

Do you have a disability?
NonePhysicalMental

Please describe your disability:

Are you a victim of physical or emotional abuse?
YesNo

Have you lost or are you at risk of losing housing or basic needs?
YesNo

Your Living Arrangements:
OwnRentOther

No. of Adults in your Home

No. of Children in Home

Household Total

Household Monthly Gross Income

Your monthly

Your Spouse’s

Other Residents’

Before Taxes & Expenses are Deducted

Gross income

TOTAL INCOME

For office use: Household income is% of poverty level.

APPLICATION FOR LEGAL ASSISTANCE UVLA CONTINUED

Applicant’s Name:

Household Assets (Total amounts for applicant, spouse and all other residents)

Please write the amount in each space or write “none”

Real Estate equity (not including residence)

Cash on hand

Equity in vehicles not used for transportation

Checking Account

Household goods (value in excess of $3000)

Savings Account

Wearing apparel (value in excess of $1500)

CD’s, Money Mkt, etc.

Is your income likely to change significantly in the near future?
YesNo

(If yes, explain how income is likely to change):

If you listed no income above, how are you supporting yourself?

Please tell us what you pay each month for: rent/mortgage:

medical care/insurance:

child care:

other (what is it?):

If your mailing address is different from your street address, please tell us your street address:

Street

City, State

County

How did you hear about our program?

If you own a home, please tell us how much equity you have in your home: $

Person filling out application (if not Applicant)

Phone

Relationship to Client

YOUR LEGAL PROBLEM:

Brief Description of Your Legal Problem:

Name(s) of Adverse/Opposing Party

Deadlines (Court dates, Answer dates, etc.)?

What County is your legal problem in?

Please tell us what you would like to do about your legal problem:

Signature

Date

FOR LEGAL SERVICES USE: Is this client eligible for services?
YesNo