Application for Legal Services

Please fill out the form below.

IMPORTANT - YOU MUST FILL OUT THE Authorization and Certification Form BEFORE FILLING OUT THE FORM BELOW

I have printed, signed, and mailed in the Authorization and Certification Form.


Have you applied for Judicare before?


If Yes, under what name?
Judicare Card #

* Name:
* Address:
* City: County: * Zip Code:
Phone: Home:
  Work:
  Cell:
Age:    
 

For your safety, what other mailing address do you want us to use if different than above?

Address City State Zip Code
   
Contact Person: Name: Phone:

List the first and last names of the people living in your household:
First Name
Last Name
Age
Relationship

List the first and last names of your minor children not living in your household:
First Name
Last Name
Age
 
 
 
 

List the first and last names of the biological parent, other than yourself, for each child listed above.:
First Name
Last Name
Name of Children in Common
 
 
 
 

Your Sex:    
Your Race: If Other:
Your Marital Status:    
Your Spouse's Name: Address:

* What is your legal problem?
When is your next court date?
In which county and state is your legal problem?
What is the name of the person or agency your legal problem is against?

Are you the victim of domestic violence?


If Yes, by whom?

Are you a Veteran?


Is some or all of your or your spouse's income primarily used for medical or nursing home expenses?


If Yes, you will be asked to provide documentation.

Are you a U.S. citizen?


If Yes, you will be required to attest to this in writing.
If No, a Judicare card will not be issued. Your application must be submitted to the Judicare office for consideration. Please provide a photocopy of the front and back sides of your resident alien card, passport, or other documents regarding your admission to the United States.

Financial Worksheet

Are you self-employed or do you own and operate a farm or business?


If Yes, you must mail a copy of your most recent Federal Income Tax return.

Gross Monthly Household Income: Include all income before taxes or deductions from wages and salaries, self-employment, and all other income received for all members of your household.
 
Applicant
Spouse
Other Household Members
Total
a. Wages/Salaries/Self-employment
b. Social Security/SSD/SSI
c. Welfare/W-2
d. Unemployment or Worker's Comp.
e. Child Support/Alimony
f. Other sources of income
g. Per Capita
(1) Add lines a-g:

Monthly Household Expenses: List only those expenses that you or your household members are currently paying.
 
Applicant
Spouse
Other Household Members
Total
a. Rent/Mortgage
b. Child Support
c. Child Care
d. Medical Insurance Premiums
(2) Add lines a-d;

Total Monthly Income: - Subtract line (2) from line (1):
Expenses may not be counted to calculate eligibility.
Assets: Include the value of all assets listed below. List only the equity value. Equity means the value of the item on today's market minus the amount owed on that item.
 
Applicant
Spouse
Other Household Members
Total
a. Cash/Checking/Savings/CDs/
Stocks/Bonds
b. Pensions/IRAs/Trusts
c. Life Insurance with Cash Surrender Value

d. Guns/Boats/ATVs/Snowmobiles/Motor Homes and Other Similar Items

e. Real Estate Other than Homestead
Add lines a-e:

IMPORTANT: Again, you must fill out the Authorization & Certification form prior to submitting this form.

         
* Validation:

Please press the Submit button only once.