NOTICE:  Required fields marked with an asterisk (*) MUST be completed in order to process the application.  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.

First Name*

Last Name*

Address*

City *

Zip Code*

Phone Number*

Date of Birth*

US Citizen*
Yes No 

Gender*
Male Female 

Disabled*
Yes No 

Domestic Violence Victim*
Yes No 

Marital Status*

Spouse (required if applicable)

Spouse's Address (required if applicable and other than above)

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 public 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*

Worker's 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 

If yes, who receives it, it's source, and amount?

Do you have a bank account?*

If yes, list type of account,(s) bank(s), and current balance(s):

Do you have stocks, bonds or other assests?*
Yes No 

If yes, list each of them and their value(s):

Do you own or are you buying a house?*
Yes No 

If yes, where is it located?

If yes, what is the value and what do you owe?

If yes, to whom do you make payments?

If yes, what is the monthly payment?

Do you own any motor vehicles?*
Yes No 

If yes, what is the make, model and year?

If yes, what is the balance owed and to whom do you make payments?

Weekly child care expense*

Weekly employment transportation costs*

Food costs*

Cost of utilities*

Long term or recurring medical & dental expenses?
Yes No 

If yes, detail the problem and expense

Type of case

Cause No

Court

Court Date

Opposing Party*

Opposing Counsel, address and phone number

Have you previously contact an attorney?*
Yes No 

Your Email*

Your Case Summary

Please input the verification code below and click "Send" to submit your application.

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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).