APPLICATION FOR ASSISTANCE

APPLICATION FOR ASSISTANCE
Welcome to LCLAS’ online application portal.

Before applying online, make sure you are eligible for free legal aid. Once your submission is submitted electronically, a LCLAS employee will process your application and follow up with you in a timely manner.

IF YOU FEAR FOR YOUR SAFETY we do NOT recommend the use of this application. Information entered online may be stored in the computer you use, and may be retrieved by someone knowledgeable. If you are concerned for your safety, please complete your application for assistance over the telephone by calling 239-334-6118.
Date of Application:*
What are you seeking assistance with?*
- Dissolution Of Marriage with minor children
- Dissolution of Marriage without minor children
- Establishment of Paternity/Time-Sharing
- Temporary Custody by Extended Family
- Step Parent Adoprtion
- Other type of assistance. (Explain in brief description field.)

Information About You
Maiden Name*
First Middle Last
Home Address*
Street Address City State / Province / Region ZIP / Postal Code
Mailing Address
Street Address City State ZIP Code
Date of Birth*
County of Residence (Not Country/USA)*
If this is a divorce:
Date of Marriage
Date of Separation

Contact Information
Home*
Work
Cell*
Email Address*

Household Income
Please list the name, relationship AND all income in the section below: (You must provide everyone's income that lives in the household.)
How many adults live in your household?*
*
Name of Household Member Relationship to you Income Amount Annually
Name of Household Member Relationship to you Income Amount Annually
Name of Household Member Relationship to you Income Amount Annually
Name of Household Member Relationship to you Income Amount Annually
Name of Household Member Relationship to you Income Amount Annually
How many children live in your household?*
Please list the name, and date of birth AND relationship to you in the box below: (Please list only children that live with you full-time.)
Name of Children Date of Birth Relationship to You
Name of Children Date of Birth Relationship to You
Name of Children Date of Birth Relationship to You
Name of Children Date of Birth Relationship to You
Name of Children Date of Birth Relationship to You

Work Information
Please provide an accurate rate of pay and how many hours. (We will not be able to accept your application without this Information.)
Name of Employer*
Telephone Number*
Address*
Street Address Address Line 2 City State ZIP Code
How long have you been there?*
Job title*
Rate of pay*
How many hours per week?
Do you receive tips?
- Yes
- No
If Yes, how much per week?

Other Sources of Income
Do you have any other source of income?*
- Yes
- No
If yes, what type of income do you receive, who receives said income and how much?

Examples of types of incomes Child Support, Disability, Social Security, Unemployment Compensation, Worker’s comp, etc. (This includes income for Children and other person’s in household)
Type of Income Name of person who receives source of income? How Much is received monthly?
Type of Income Name of person who receives source of income? How Much is received monthly?
Type of Income Name of person who receives source of income? How Much is received monthly?
Type of Income Name of person who receives source of income? How Much is received monthly?
Type of Income Name of person who receives source of income? How Much is received monthly?
Type of Income Name of person who receives source of income? How Much is received monthly?
Who pays household expenses?*
Do you own a house?*
- Yes
- No
If yes, value*
Do you own a car?*
- Yes
- No
If yes, Make/Model*
Value*

Additional Information
How long have you lived in Florida before today?*
Have you ever been charged with a crime?*
- Yes
- No
If yes, for what and when?
Has the opposing party filed any paperwork with the court?*
- Yes
- No
If yes, for what?
If yes, what date were you served?
Have you talked with another attorney about this?*
- Yes
- No
If yes, who?
Please give a brief description of what you want us to help you with*

Lee County Legal Aid Society, Inc.
Application for Assistance*
- Accept
I, understand that I am completing this application for purposes of determination of my eligibility to receive legal assistance from Lee County Legal Aid Society, and my completion of this application in no way creates an attorney client relationship or privilege. I also understand that should my application not be completed fully, including household income and opposing party’s physical address, Lee County application for assistance be denied, my application will be shredded without any further notice to me. No application is denied for reasons of race, sex, creed, color, religion, age, national origin, marital status, disability, or sexual orientation.
Privacy
The information you provide to us will be treated as confidential. We will use the information you provide in the application only to determine your eligibility for services and, if we can assist you, to aid us in providing those services. If you are using a public computer or computer that does not belong to you, be sure to close out of the browser completely when you are done so that other users cannot view your application.
No Guarantee
This application is only a preliminary screening. Completing the application does not make you a client of LCLAS and does not create an attorney-client relationship. Completing the application does not mean that LCLAS will be able to help you. After the Executive Director reviews your application she will then determine if you will be seen by one of our staff Attorneys. We do our best to provide some assistance to everyone who is eligible, but you may not qualify for services. Some applicants may get an attorney to represent them, while others may get legal advice, a referral, or some other assistance. Decisions about what service can be given are based the nature of the individual case.

Step 1 of 9

APPLICATION FOR ASSISTANCE

Information About You

If this is a divorce:

Contact Information

Household Income

Work Information

Other Sources of Income

Additional Information

INFORMATION ABOUT THE OTHER PARTY

Contact Information

Children

Contact Information

DEMOGRAPHIC INFORMATION

Lee County Legal Aid Society, Inc.

Privacy

No Guarantee