Pro Bono Intake Form NOTICE: The information obtained on this form will be used to help determine if we can assist you with your legal needs. The information you provide is confidential but it must be completed and truthful. If you are accepted as a client, and if it is later determined that the information you have provided on this form is incomplete or untrue, the Hendricks County Pro Bono Program or your assigned attorney may terminate the attorney/client relationship. *indicates required fields    *Date:   *First Name:   *Last Name:   *Address:   *Phone Number:   *Date of Birth:   *U.S. Citizen:   *Gender:  male  female   *Ethnicity:   *Disabled:  yes  no   *Domectic Violence Victim:  yes  no   *Martial Status:   *Spouse:   Spouse's Address if different:   *Your Monthly Income:   *Your Employer and address:   *Spouse's Monthly Income:   *Spouse's Employer and address:   *List all in household, incl. kids & monthly income:   *Does anyone receive pubilc assistance?:  yes  no   *TANF:  yes  no   *Food Stamps:  yes  no   *Fuel Assistance:  yes  no   *Disability:  yes  no   *AFDC:  yes  no   *VA:  yes  no   *Social Security:  yes  no   *Workers Comp:  yes  no   *Medicaid:  yes  no   If yes to any, who receives it and the amount:   *Any other sources of income to the household?:  yes  no   Who receives it, it's source, and amount:   *Do you have a bank account?:  yes  no   *List type of account, bank, and current balance:   *Do you have stocks, bonds or other assests?:  yes  no   If so, list them and their value.:   *Do you own or are you buying your house?:  yes  no   If so, where is it located?:   *What is the value and what do you owe?:   *To whom do you make the payments?:   *Do you own any motor vehicles?:  yes  no   *Make, Model, Year:   *Balance owed and whom do you make payments:   *Monthly House Payment:   *Weekly child care expense:   *Weekly employment transportation costs:   *Food costs:   *Cost of Utilities:   *Long term or recurring medical & dental expenses?:  yes  no   Detail problem and expense:   *Type of Case:   *Cause No:   *Court:   *Court Date:   *Opposing Party:   *Opposing Counsel, address, phone:   *Previously consulted attorney?:  yes  no   *Case Summary: By clicking SUBMIT, I certify and affirm that I have read the above or had it read to me; I fully understand the information contained herein, and it is true and correct to the best of my knowledge. I request that this information be considered in determining my eligibility to receive free legal services from the Hendricks County Pro Bono Program. I hereby authorize the Hendricks County Pro Bono Program to release records and information pertaining to my case to the pro bono attorney(s).
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