For Evaluation Only.

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Edited by VeryPDF PDF Editor Version 2.6
Application for Assistance
United States Legal Research Group, Inc.
All the information that you provide in this application is strictly confidential.

1. What type of problem do you need help with?

Divorce Custody Tenant / Landlord Name Change Bankruptcy
Collection Other:

2. Applicant Information:
Your SSN (last 4 digits only): Date of Birth:
(mm/dd/yyyy)
000-00- M F
Sex:
Your Name
Full name
Age:
Your mailing address: Your phone numbers:
Home: Ex:

Work: Ex:
Enter city Montana Enter ZIP
Other contact number:
Is it safe to write you at the above address? Ex:
(If no, include safe contact info on last page) Is it safe to call you at the above phone
numbers? (If no, include safe
Yes No Yes No info on last page)
Your e-mail address (optional): Your marital status:
Single Married Divorced
Widowed Other

Other names you have gone by: Your race (check all that apply):
Maiden name: White African-American
Asian or Pacific Islander
Hispanic Other:
Former name(s):
Native American -- Tribe:
Do you speak a language other than English
at home? Yes No

Spanish Russian
Other

Citizenship (if you are a citizen of the U.S. please If you are NOT a US citizen:
sign OR type your name below): a. Are you a resident alien?
Yes AIN:
[Attach copy of your green card]
I am a citizen of the United States: No (go to next question)
b. Do you have a green card? Yes No
c. Are your children citizens? Yes No
05/20/2010 d. Have you filed for adjustment of status to
Signature Date permanent resident? Yes No

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For Evaluation Only.
Copyright (c) by VeryPDF.com Inc
Edited by VeryPDF PDF Editor Version 2.6
3. Provide the details of the person you are having problems with (for example in a divorce
that person would be your spouse, for custody that might be the other parent -- not you, for housing --
your landlord, etc.)
Full name of person: Address of person:

Full name

Enter city Montana

SSN of person (last 4 digits if you know it):
000-00- Enter ZIP

Date of Birth of person (if you know it): Is this person represented by an attorney?
Yes No
If yes, name of attorney:
Age:
Other names this person has gone by: How did you hear about the Montana Legal
Services Association?
Maiden Name: Friend/Relative Prior Use
Former name(s): Social Agency Court
MontanaLawHelp.org Other:

4. Your household (list the names of each member of your household, their relationship
to you (for example, boyfriend, son, daughter, spouse, etc.)
Does this person
Full name Relationship Age live with you?
Yes No
Yes No
Yes No
Yes No

5. Household income information:

a. Are you employed? Yes No
If yes, how much money do you earn each month before taxes?
Do you get food stamps? Yes No
b. Is anyone else in your household employed? Yes No If yes, who?
If yes, how much money do he/she/they earn each month before taxes?

Other income information: (please list monthly amounts or zero (0) if none received):
Type of Income You Other person
SSI
Soc. Sec. Disability
Soc. Sec. Retirement
Child Support
TANF (Welfare)
Veteran’s Benefits
Unemployment
Worker’s Compensation
Other:
Other:

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Do you have any reason to believe that your income is likely to change a lot in the near future?
Yes No

6. Asset information (If you or anyone in your household has any of the following, please fill in the
value of each item listed below. For example, if you or someone in your household has a checking or
saving account and there is no money in it – write down zero (0)):

Checking, Savings, Cash Assets:

Type of Income You Other person

Checking account
Savings account
CD’s
Stocks or Bonds
IRA
Other:
Other:

Vehicles (please list all vehicles):

Year Model Value Money Owing

Recreational equipment (boats, guns, jet skis, horses, motorcycles, etc.):

Year Model Value Money Owing

Real Estate:
Do you: Own a home? Rent an apartment or home? Live with relatives?
Live with friends? Other?
If you own a home, fill in information below.
Description (physical address) Value Money Owing

Do you own any other property other than where you live?
(If you own a 2nd home, land, or other real property, list below):

Description (e.g., 2nd home, cabin, etc.) Value Money Owing

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 Other Property -- Do you have any personal property other than household furnishings?
(If yes, please list below):

Description Value Money Owing

7. Hearing and Deadlines:

a. Have you been served with any court documents? Yes No
If yes, what date were you served with papers?
b. Are there any deadlines that you know of? Yes No
If yes, what is the deadline?
c. Is there a hearing scheduled? Yes No
If yes, what is the date and time of the hearing? Date: Time:

8. Safe Contact Information (if different from page 2 of this application):

Mailing Address:

Enter city Montana Enter ZIP

Phone Number(s):

9. Briefly describe your problem (if you need additional room, please attach a separate page):

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