Disability Legal Services Of Indiana Application For Assistance (Page 3 of 3) in pdf

Disability Legal Services Of Indiana Application For Assistance Page 3

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III.

CERTIFICATION AND UNDERSTANDING OF APPLICATION TERMS

Applicant understands that completing this application for assistance does not

create any attorney-client relationship and does not guarantee me or anyone in

my household representation by DLSI or an attorney. I further understand that

DLSI will attempt to inform me within three weeks whether I qualify for legal

representation based upon DLSI’s eligibility guidelines. 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

understand that I will be required to verify the financial information in this form.

I hereby request that this application be considered in determining eligibility to

receive legal services from DLSI.

Date: ________________________ Signature: ________________________________

Please return this form to Disability Legal Services of Indiana, Inc.

Mail: 5954 North College Ave, Indianapolis, IN 46220

Fax: 317-282-0608

Email:

FOR DLSI USE ONLY:

Date received in office: ________________________

Household Members

Poverty Guideline

Household Income

Qualified Household Expenses

Adjusted Household Income

Application: ( ) accepted under 150%

( ) accepted 150-200%

( ) accepted 200-250%

( ) accepted 250-300%

( ) rejected

Eligibility letter sent: ______________________

Attorney assigned: ________________________________

Disability Legal Services Of Indiana Application For Assistance Page 3