Disability Legal Services Of Indiana Application For Assistance
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3DISABILITY LEGAL SERVICES OF INDIANA, INC.
APPLICATION FOR ASSISTANCE
NOTICE:
The information on this form will be used to help determine if
Disability Legal Services of Indiana, Inc. (DLSI) can assist you with your legal
needs.
The information you provide must be truthful, to the best of your
knowledge. 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, DLSI or
your assigned attorney may terminate his/her attorney-client relationship with
you and DLSI will bear no responsibility to provide you with another attorney.
Are you:
( ) a person with a disability
( ) a parent or guardian of someone with a disability
How would you classify your legal needs?
( ) education dispute
( ) guardianship matter
( ) estate planning matter
I.
INFORMATION ABOUT YOU (Please Print)
Name: __________________________
Date of Birth: ___________________
Address: ________________________
Home Phone: __________________
________________________
Cell Phone: ____________________
County: ________________________
Email: _________________________
Marital Status: ___________________
Gender: ________________________
Primary Language: _____________
Ethnicity (optional): ______________
Citizenship: ____________________
II.
FINANCIAL INFORMATION
In order to determine if you qualify for our services, please provide the following
financial information for all persons living in your home.
Name: __________________________
Monthly income:________________
Age: ____________________________
Source of income:_______________
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D I S A B I L I T Y L E G A L S E R V I C E S I N D I A N A
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