Legal Aid of Northwest Texas Application (For Legal Assistance)

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LEGAL AID OF NORTHWEST TEXAS	 	
APPLICATION	 	
(For	 Legal Assistance)	 	
 
APPLICANT (YOU):	 	
 
Name	:   	 	 	  M	iddle:	  	 	  Last 	:  	 	 	 	   M	: _____ 	F: _____	 	
 
Please list	 any other names by which you are	 known, including	:  	
  
M	aiden name (if any)	:  	 	 	 	 	           	 	
Former married names (if any)	:  	 	 	 	  	
Nicknames	 you may have:	   	 	 	 	 	
 
SSN: 	  	 	 	 	 	    	DOB: 	 	 	 	 	   Age	:   	 	 	     	 	
Physical 	Address:	 	 	 	 	 	 	 	 	  Apt. #:	 	   City:	  	 	 	
Mailing Address: 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	
County:	 	 	 	 	 	  State:	  	 	 	 	  Zip:	  	 	 	 	
Home Phone: 	(     )	 	 	 	Cell Phone: 	(     )	 	 	 	 Work Phone: 	(     )	 	 	 	 	
Driver’s License No.: 	  	 	 	 	 	 	 	 	 	 	 	 	 	
 
County of Dispute	: (what county is this case in) 	 	 	 	 	 	 	 	 	 	 	
 
Single? ____  	 Married	? ____  	 Common	 Law? 	_____	   Separated? 	_____	    Divorced? 	_____	  Widow	ed	? _____	  	
  
Current Living Situation:	 	Own	_____	 	Rent 	_____    Family_____	 	Friends	 _____	    Homeless	 _____	 	
 
Have you ever served in the military including the reserves or National Guard? 	 	 	 	
Has anyone in your household ever se	rved in the military including the reserves or National Guard? 	 	 	   	
Are you a U.S. Citizen?	 	 	 	    	Are you a Migrant worker? 	  	 	 	
Are you disabled? 	 	 	 	 	 	Are you a victim of abuse? 	 	 	 	 	
 
OCCUPATION	: (C	heck	 one	) 	
 
  Employed	 ________	      	 Retired	  ___________   	Not	 Employed	 	  __________ 	 Self	-Employed	 __________	 	
 
PRIMARY LANGUAGE:	 (C	heck	 one	) 	
 
English 	_________	 	Spanish	 _________	 	Chinese	 _________	 	French	 ________	_ German	 _________	_ 	
Japanese 	_________	 Korean	  _________	 	Vietnamese	 _________ Sign	 Lang	uage	______   	Other	 _______	 	 	
 	 	 	 	 	 	
RACE	: (Check	 one	) 	
 
_____ Black/African American _____ Hispanic Origin 	      	_____ Asian or Pacific Islander 	 	
_____White/Caucasian/Anglo   _____ Native American	 	_____Refuse	d to Identify	 	_____	Other

OPPOSING	 PARTY	 (person, persons or organization you are having a legal problem with	): 	
 
Name	 (Individual)	:   	 	 	   M	iddle:	  	 	 	  Last	:   	 	 	 	 	
 
Please list any other names by which the adverse (opposing) party is known, including	:   	
 
Their 	M	aiden name (if any)	:  	 	 	 	 	   	
Former	 M	arried names (if any)	:  	 	 	 	 	  	
And any N	icknames they may have:	  	 	 	 	 	
 
Address:	  	 	 	 	 	 	   Apt. #	  	  City:	   	 	 	 	 	 	
State:	   	  Zip:	   	 	   County:	  	 	 	 	  Phone #:	  	 	 	 	  	
SSN:	   	 	 	  DOB:	  	 	 	  Age:	   	 Male	  	    Female	 	 	 	
Race:	   	 	 	 	 	 	US Citizen	:  	 	 Y 	   	 	N   	
 
Name (Organization): 	 	 	 	 	 	 	 	 	 	 	 	 	 	
 
Address: 	 	 	 	 	 	 	   Apt. # 	 	  City: 	  	 	 	 	 	 	
State: 	  	  Zip: 	  	 	   County: 	 	 	 	 	  Phone #: 	 	 	 	 	  	
 
 	 	
NUMBER OF PEOPLE IN YOUR HOUSEHOLD	:  	
 
ADULTS	  	 	 	 	 	CHILDREN(	under the age of 18	)  	 	 	 	
 	 	
Name of each	 person 	
living in your ho	usehold	 	
including yourself, 	
children, husband if still 	
living together, etc.	: 	
 	
Relation	ship	 	Gender	 	
M / F	 	
Age	 	Social Security	 	
Number	 	
Date of 
Birth	 	
 	
Type of	  income	 	
(Employment, Child	 	
or Spousal	 Support, 	
Retirement	, Rent, 	
Unemployment, VA 
SSI/SSD, 	etc.	)        	 	
Gross 
Monthly	 	
Amount

FINANCIAL STATEMENT	 	
 	
Occupation:	 	
 
Place of Employment: 	 	 	 	 	 	 	Monthly Gross Income: 	 	 	 	 	
Spouse’s 	Monthly Gross Income: _____________________	 	
Do you have access to your spouse’s income? _____ Y	 	_____N	 	
 
Please note the kind and 	monthly	 amount of any government benefits you receive:	 	
 
TAN	F: $ 	 	  Food Stamps: $	 	 	 	 	HUD: 	$ 	 	 SSI: $	  	 	 	
Medicaid: $	 	 	  Social Security: $	 	 	 	 WIC:	  	 	  Disability: $	  	 	 	
Other: (type and amount)	  	 	 	 	 	 	 	 	 	 	 	 	
 	 	
Do you have any other form of income? 	____	Y 	____	N  	 If so, please note the 	monthly	 amount	 below:	 	
Child Support: $	 	 	 	 	  Retirement: $	  	 	 	  V.A.:	  	 	 	  	
Unemployment: $	 	 	 	 	  Annuity	: $	 	 	 	 	  Other:	 	 	 	  	
 
Is any other person helping to support you? 	____	Y 	____	N 	    	If so, who? 	  	 	 	 	 	 	
 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	
What is their relationship to you? 	 	 	 	 	 	 	 	 	 	 	 	 	
What support do they provide? 	 	 	 	 	 	 	 	 	 	 	 	 	
 
Do you have any reason to believe that 	your income is likely to change significantly in the near future?	   	
Check o	ne: Yes 	 	 	 	No	  	 	 	
 
ASSETS	: 	
 
Do you own your	 home? 	 	  What is the Mortgage payment/note? $	   	   Value of Home: $	 	 	 	 	
Do you rent: 	 	 	   What is the amount of your rental payment? $	  	 	 	 	 	 	 	
Do you own any other land, house, or other real estate? 	  	 	  If so, please list:	 	
 	
Type of Property	 	Owner	 	Value	 	
    	 	
 	 	             	 	
 	 	 	
 	 	 	
 
Do you own a motor vehicle? 	 	 	    	Year/Make/Model: 	 	 	 	 	 	 	 	 	
Do you own any other vehicles (including boats	, RVs, etc.	)? 	 	 	   If so, please list:	 	
 	
Year	 	Make	 	Model	 	Titled Owner

Do you have a bank account? ____Y ____N    Checking? $	  	 	 	  Savings? $	 	 	 	 	
Please give the total amount of money in all bank 	accounts: $	 	 	 	 	 	 	 	 	
Do you have any certificates of deposit? ___Y ___N  How much: $	 	 	 	 	 	 	 	 	
Do you own any stocks or bonds? ___Y ___N  If so, what is the worth: $	  	 	 	 	 	    	
Do you have any cash? ___Y ___N  	 If so, amount $	 	 	 	 	 	 	 	 	    	
Do you have any other accounts with any financial institution (bank, insurance company, credit union, escrow account, 
savings and loan)? 	  ___Y ___N 	   If so, amount: $	 	 	 	 	 	
 
Please list any of the following which apply.  (If there is not a specific monthly	 amount, or if the amount varies, please 	
note that in the appropriate place.  If you only know a 	weekly	 or hourly amount, please indicate that in the “monthly 	
payment” area.)	  	
 
 	
Type of Expense	 	Monthly Payment	 	Who do you pay?	 	
 	
Child Support	, Medical 	
Support, Spousal Support	    	
 	 	
Child Care	 Expenses	 	 	 	
Elderly Care	 Expenses	 	 	 	
Unreimbursed 	Medical 	
Expenses/ Health Insurance 
Premiums	 	
 	 	
Job of Educational Training 
Expenses	 	
 	 	
Work	 or School	 Related 	
Transportation	 Expenses	 	
 	 	
Back Income Taxes	 	 	 	
Back 	Property Taxes	 	 	 	
Bankruptcy	 or other Court	-	
ordered Judgment	 	
 	 	
Other Debts: (List what debt is 
for)	 	
 	 	
 	 	 	
 
This is to certify that the information I have provided above is true and correct to the best of my 
knowledge.	   I understand that lawyers may not 	assist new clients in any matters that are adverse to 	
existing or former client’s interests.  Legal Aid of NorthWest Texas will conduct a Conflict of Interest 
check.  If it is determined that a conflict of interest exist, LANWT may not be able to provide m	e with 	
representation in this matter.	 	
 
 
DATE: 	 	 	 	 	 	SIGNED: 	 	 	 	 	 	 	 	 	 	
 
 	 	 	 	 	 	Print Name: