Nevada Attorney General - Office Of Military Legal Assistance Wills Workshop Intake Page 2
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3TOTAL HOUSEHOLD MONTHLY INCOME
(Income
before
taxes and other deductions)
Your Income:
Other Household Member Income:
(Please State Relationship) ____________________
Employment Income
$___________
Employment Income
$___________
(including tips
(including tips)
Social Security/Disability/SSI
$___________
Social Security/Disability/SSI
$___________
TANF
$___________
TANF
$___________
Food Stamps
$___________
Food Stamps
$___________
Unemployment/Worker Comp
$___________
Unemployment/Worker Comp
$___________
Child Support
$___________
Child Support
$___________
Pension
$___________
Pension
$___________
Veterans Benefits
$___________
Veterans Benefits
$___________
Tribal Payments
$___________
Tribal Payments
$___________
Recurring Gifts
$___________
Recurring Gifts
$___________
Prospective Income
$___________
Prospective Income
$___________
Other Income
$___________
Other Income
$___________
TOTAL HOUSEHOLD INCOME $__________________
ASSETS:
OTHER ASSETS:
Cash (on hand and in bank)
$____________
Value of Second Home
$____________
Tools/Equipment/Other
$____________
Value of Second Car
$____________
Home Equity
$____________
Value of Boat/ATV/Motorcycle
$____________
Real Property
$____________
Value of Household Goods > $12K
$____________
Auto Equity
$____________
Value of Pension/IRA/401(k)/Trust/
Tribal Settlement Distributions
$____________
403(b)/KEOGH > $500K
$____________
Other
$____________
Stocks/Bonds/Mutual Funds/CDs
$____________
Total Assets Valued
$_____________
CITIZENSHIP DECLARATION
I hereby declare that I am currently a citizen of the United States of America.
Client Signature__________________________
Date _______________________________
Print Name_____________________________
I have read the information above and attest that it is correct to the best of my knowledge, information and belief.
Completing this intake form does not establish an attorney/client relationship. The Nevada Office of the Attorney
General and Nevada Legal Services is not offering or agreeing to represent me in any legal matter. Assistance is
based only on a brief review of the disclosed facts.
Signature:______________________________
Date:_________________
Please feel free to provide us your comments regarding your experience with the Nevada Attorney General Office
of Military Legal Assistance or Nevada Legal Services.
If you do not wish to receive emails concerning updates and notifications from OMLA check here ☐
For Attorney Use:
Date:_________________
Name of Attorney: ______________________________
Documents Prepared:
_______________________________________________________________________________________
Page 2
OMLA/NLS – Intake Form - Veteran/Rev. 6.22.15
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