Disability Legal Services Of Indiana Application For Assistance Page 2
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Spouse/Partner: __________________
Monthly income:________________
Age: ____________________________
Source of income:_______________
Child/Dependent: ________________
Monthly income:________________
Age: ____________________________
Source of income:_______________
Child/Dependent: ________________
Monthly income:________________
Age: ____________________________
Source of income:_______________
Child/Dependent: ________________
Monthly income:________________
Age: ____________________________
Source of income:_______________
Does anyone in the household receive public assistance or services including, but
not limited to:
TANF
( )
SSI
( )
Head Start
( )
SNAP
( )
SSDI
( )
CHIP
( )
Worker’s Comp. ( )
Medicaid
( )
Waiver
( )
Do you own any of the following assets: If so, state the current value.
YES
NO
Value/Balance
Home
( )
( )
$_____________________________
Vehicle(s)
( )
( )
$_____________________________
Checking Account
( )
( )
$_____________________________
Savings Account
( )
( )
$_____________________________
Real Estate
( )
( )
$_____________________________
Investment Accounts
( )
( )
$_____________________________
Retirement Accounts
( )
( )
$_____________________________
Trust Accounts
( )
( )
$_____________________________
Do you have any of the following expenses that may be considered in
determining eligibility? If so, please describe in “Other”.
YES
NO
Monthly Cost
Child Care Expenses
( )
( )
$___________
Medical Insurance Premiums (after tax) ( )
( )
$___________
Unreimbursed Medical Expenses
( )
( )
$___________
Disability-related Expenses
( )
( )
$___________
Other:
$___________
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