Eligibility Application


ASSIGNED COUNSEL PROGRAM Tompkins and Schuyler County 171 E. State/MLK Jr. Street, Suite 223 Ithaca, NY 14850 Phone: 607-272-7487 Fax: 607-272-7489

ELIGIBILITY APPLICATION FOR LEGAL SERVICES
Application Date:*field type date

Your Personal Information

First Name:*field type single line
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Last Name:*field type single line
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Are you known by any other names?*field type radio button
Are you known by any other names?YesNo
Alternate Name(s)field type single line
Row 1× Alternate Name(s)field type single line
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Mailing Street Address:field type single line
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Street Address 2field type single line
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City:field type single line
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State:field type drop-down
Zip Code:field type single line
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Phone Number:field type single line
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Alternate Phone Number:field type single line
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Work Number (include extension)field type single line
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What is your immigration status?field type drop-down
Do you have an email address?*field type radio button
Do you have an email address?YesNo
Email Addressfield type email
Applicant Date of Birth:field type date
Current Status:field type radio button
Current Status:SingleMarriedMarried but separatedDivorcedSeparatedWidowed
Spouse's Full Name:field type single line
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Total number of people in the household - including yourself?field type single line
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	Alternate Name(s)field type single line
Row 1×	Alternate Name(s)field type single line Input blocked. Maximum character limit of 4000 characters reached.	×

Case Information

Type of Matter:*field type radio button
Type of Matter:Family CourtCriminal Court
CourtTypeHiddenfield type single line
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Court where case will be heard:*field type drop-down
Is this the initial petition?field type radio button
Is this the initial petition?YesNo
Is this case an appeal?field type radio button
Is this case an appeal?YesNo
IsCaseTypeAppeals_Hiddenfield type single line
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Specify Other Court Type:field type single line
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Proceedingsfield type single line
Row 1× Proceedingsfield type single line
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Appeal Numberfield type single line
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Appeal Datefield type date
Court:*field type drop-down
CourtIDfield type single line
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Judge:*field type drop-down
JudgeId_Hiddenfield type single line
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Next Court Date:field type date
Appearance Time:field type single line
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Charges:*field type single line
Row 1× Charges:*field type single line
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Family File Number:field type single line
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Docket Number:field type single line
Row 1× Docket Number:field type single line
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What is your relationship to the case?field type radio button
What is your relationship to the case?PetitionerRespondentPetitioner and RespondentInterested Party

	Proceedingsfield type single line
Row 1×	Proceedingsfield type single line Input blocked. Maximum character limit of 4000 characters reached.	×

	Charges:*field type single line
Row 1×	Charges:*field type single line Input blocked. Maximum character limit of 4000 characters reached.	×

	Docket Number:field type single line
Row 1×	Docket Number:field type single line Input blocked. Maximum character limit of 4000 characters reached.	×

Opposing Party/Parties Names:

	Namefield type single line	Date of Birth (if known)field type date	Relationship To Childfield type drop-down	field type single line
Row 1×	Namefield type single line Input blocked. Maximum character limit of 4000 characters reached.	Date of Birth (if known)field type date	Relationship To Childfield type drop-down	field type single line Input blocked. Maximum character limit of 4000 characters reached.	×

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Income

Do you work?field type radio button
Do you work?YesNo
Where do you work?field type single line
Input blocked. Maximum character limit of 4000 characters reached.
Your total net (after taxes) income:field type currency
$
Net Income is:field type drop-down
Are there other members of the household that work?field type radio button
Are there other members of the household that work?YesNo
Do you receive Public Assistance?field type radio button
Do you receive Public Assistance?YesNo
Income of other members of the household:field type currency
$
Other Household Income is:field type drop-down
What is your relationship to other member(s) of household earning income?field type single line
Input blocked. Maximum character limit of 4000 characters reached.
Do you have any income?field type radio button
Do you have any income?YesNo

State any income from the following sources: (indicate amounts per month)

	Sourcefield type drop-down	Monthly Amountfield type currency	Additional Infofield type single line
Row 1×	Sourcefield type drop-down	Monthly Amountfield type currency $	Additional Infofield type single line Input blocked. Maximum character limit of 4000 characters reached.	×

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If no income how do you support yourself?*field type single line
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Assets

	Assetfield type drop-down	Valuefield type currency	Additional Infofield type single line
Row 1×	Assetfield type drop-down	Valuefield type currency $	Additional Infofield type single line Input blocked. Maximum character limit of 4000 characters reached.	×

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Expenses

	Expensefield type drop-down	Monthly Amountfield type currency	Additional Infofield type single line
Row 1×	Expensefield type drop-down	Monthly Amountfield type currency $	Additional Infofield type single line Input blocked. Maximum character limit of 4000 characters reached.	×

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Upload Income Verification Documents

Have you been represented by an Attorney in the past?*field type radio button
Have you been represented by an Attorney in the past?YesNo
Past Attorney*field type single line
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Specific Attorney Requestedfield type single line
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Do you currently have a retained attorney for a procedure that this office does not cover?field type radio button
Do you currently have a retained attorney for a procedure that this office does not cover?YesNo
File Uploadfield type file upload
Drop files here
You have reached the maximum file limit: .
field type checkbox
Check box if you are a veteran and/or a current or former member of the United States military.

Declaration*field type checkbox
DeclarationI declare that I have examined the above statements made by me and to the best of my knowledge and belief, they are true and correct. I hereby authorize this Court, or its representative, to verify the answers given to this affidavit. In order to verify my answers, I hereby grant permission to the Department of Social Services, the Social Security Administration and to any banks, credit institution, or other lending institutions to release information regarding the information contained herein to the Tompkins County Assigned Counsel Program Administration Office.
PreviousInstanceIDfield type single line
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Signature*field type signature
Signature Datefield type date
Date will be captured on form submission
PreviousSubmissionIDfield type single line
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Usernamefield type single line
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