LCLA67@leecountylegalaid.org
+1-239-334-6118
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Board Members
Christopher Whitney, Esq. President
Lori Clifford, Esq. Vice-President
Howard Atkin, Esq.
Marisa Boysen, Esq.
Nicole R. Brunswick, Esq.
R. Thomas Corbin, Esq. Member at Large
Matt Dinkel
Hank Hendry, Esq.
Destiney Smith, Esq.
About Us
Staff
Blair J. DeMinico, Esq., Legal Director
Eunice Gedeon, Esq., Staff Attorney
Veronica Nieves, Paralegal/Office Manager
Aubree Horton, Executive Assistant/Paralegal
“Receptionist”
Andrew J. Banyai, Esq., Executive Director
Contact Us
Lend A Hand
Volunteer
Become a Sustaining Law Firm
Make A Donation
Contact Us
Home
Apply Online
Apply Now
Cases We Handle
FAQs
Eligibility
Resources
E-Resources
Forms and Materials
Board Members
Christopher Whitney, Esq. President
Lori Clifford, Esq. Vice-President
Howard Atkin, Esq.
Marisa Boysen, Esq.
Nicole R. Brunswick, Esq.
R. Thomas Corbin, Esq. Member at Large
Matt Dinkel
Hank Hendry, Esq.
Destiney Smith, Esq.
About Us
Staff
Blair J. DeMinico, Esq., Legal Director
Eunice Gedeon, Esq., Staff Attorney
Veronica Nieves, Paralegal/Office Manager
Aubree Horton, Executive Assistant/Paralegal
“Receptionist”
Andrew J. Banyai, Esq., Executive Director
Contact Us
Lend A Hand
Volunteer
Become a Sustaining Law Firm
Make A Donation
Contact Us
APPLICATION FOR ASSISTANCE
Step 1 of 9
11%
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 SAFET
Y 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
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
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
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
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
*
INFORMATION ABOUT THE OTHER PARTY
Your application WILL NOT be accepted if you do not provide a valid address for the other party. We WILL NOT be able to represent you or issue any required documents to the other party. PLEASE PROVIDE A VALID ADDRESS. NO PO BOXES.
Name
*
First
Middle
Last
Maiden/Former Name (If this does not apply, please re enter last name)
*
Home Address
*
Street Address
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Mailing Address
Street Address
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Date of Birth
*
County of Residence
*
Contact Information
Home
Work
Cell
Email Address
Does the opposing party have an attorney?
*
Yes
No
If yes, who?
Children
Do you and the opposing party have any children in common?
*
Yes
No
If yes, please list children below:
Name
Date of Birth
Who do they reside with?
Name
Date of Birth
Who do they reside with?
Name
Date of Birth
Who do they reside with?
Name
Date of Birth
Who do they reside with?
Name
Date of Birth
Who do they reside with?
Contact Information
Name of Employer
*
Telephone number
*
Address
*
Street Address
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
How long has opposing party been there?
*
Job title
Rate of Pay
How many hours per week?
DEMOGRAPHIC INFORMATION
Please provide YOUR demographic information.
Sex
Male
Female
Race
White
Black
Asian
Native American
Ethnicity
Hispanic
Non-Hispanic
Language
English
Spanish
Are you a Veteran?
Yes
No
How did you hear about our office?
*
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.
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