Before You Begin Please do not submit multiple applications as it may delay the processing of your application. If you applied more than 3 weeks ago, you may contact the office for a status. Online Application Step 1 of 9 11% APPLICATION FOR ASSISTANCEWelcome 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.Date of Application:* What are you seeking assistance with?*New ActionPending ActionModification of Existing Court OrderCase Number for Existing Order*County / Location of Court Issuing Existing Order*At this time we are not accepting modifications. You may contact the Clerk of Court at 239-533-2835 to make a Self Help Center appointment. Information About YouCurrent Full Legal Name* First Middle Last Maiden Name First Middle Last List all other names you have previously been known byHome Address* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Mailing Address Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Date of Birth* County of Residence (Not Country/USA)*If your county of residence is outside of Lee county, we may not be able to provide any services without a referral from another Legal Aid organization.DivorceIs this a divorce case?*YesNoDate of Marriage* Date of Separation* Contact InformationHome Phone*Work PhoneCell Phone*Email Address* Correspondence from this agency will be either phone or email address so make sure you can receive correspondence at submitted email address and phone number. Household IncomePlease list the name, relationship AND all income in the section below: (You must provide name and income for all adults living in the household. Otherwise application will be rejected. If you provide false information your application will be rejected.) How many adults live in your household?*List all household members (including yourself) and income* Your name Relationship to you Income Amount Annually Name of Adult in Household Relationship to you Income Amount Annually Name of Adult in Household Relationship to you Income Amount Annually Name of Adult in Household Relationship to you Income Amount Annually Name of Adult in Household 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 Child Date of Birth Relationship to You Name of Child Date of Birth Relationship to You Name of Child Date of Birth Relationship to You Name of Child Date of Birth Relationship to You Name of Child Date of Birth Relationship to You Work InformationPlease provide an accurate rate of pay and how many hours. (We will not be able to accept your application without this Information.) Are you Unemployed? Unemployed Name of Employer*Telephone Number*Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code How long have you been there?*Job title*Rate of pay*Your rate of pay is per*hourdayweekmonthyearHow many hours per week do you work?*Do you receive tips?*YesNoIf Yes, how much per week? Other Sources of IncomeDo you have any other source of income?*YesNoIf yes, what type of income do you receive, who receives said income and how much? Examples of types of income: Additional job(s), Child Support, Disability, Social Security, Unemployment Compensation, Worker’s comp, etc. (This includes income for Children and other person’s in household)Other / Additional JobsName of person receiving incomeAmount of income received Click + to enter additional jobsChild SupportName of ChildAmount of child support received Click + to enter additional sources of child supportDisabilityName of person receiving disabilityAmount of disability received Click + to enter additional sources of disabilitySocial SecurityName of person receiving Social SecurityAmount of Social Security received Click + to enter additional sources of Social SecurityUnemploymentName of person receiving unemploymentAmount of unemployment received Click + to enter additional sources of unemploymentWorkers CompName of person receiving Workers' CompAmount of Workers Comp received Click + to enter additional sources of Workers' CompOther sources of incomeType of IncomeName of person receiving other incomeAmount of other income received Click + to enter additional sources of other incomeWho pays household expenses?*Do you own a house?*YesNoIf yes, value*Do you own a car?*YesNoIf yes, Make/Model*Value* Additional InformationAll questions must be answered honestly and completely to the best of your ability. We may not be able to help if false, fraudulent or incomplete information is submitted.How long have you lived in Florida before today?*Have you ever been charged with a crime?*YesNoWhat were you charged for and when?*Where were you charged?*Enter city / county / state/ jurisdictionHave you been served with legal documents?*YesNoFor what were you served legal documents?*What date were you served legal documents?* Case number for legal documents served*For which county/state were you served legal documents?*Are you currently represented by an attorney in this matter?*YesNoWho is representing you?*Please give a brief description of what you want us to help you with* INFORMATION ABOUT THE OTHER PARTYYour application WILL NOT be accepted if you do not provide a valid address for the other party. PLEASE PROVIDE A VALID ADDRESS. NO PO BOXES.Opposing Party Name* First Middle Last Opposing Party Maiden/Former Name (If this does not apply, please re enter last name)*Opposing Party Home Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Opposing Party Mailing Address Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Opposing Party Date of Birth* Opposing Party County of Residence*Contact InformationOpposing Party Home PhoneOpposing Party Work PhoneOpposing Party Cell PhoneOpposing Party Email Address Does the opposing party have an attorney?*YesNoDon't KnowWho is the opposing party's attorney?*Children in CommonDo you and the opposing party have any children in common?*YesNoIf yes, please list children below:List children in common*Name of ChildDate of BirthWho does child reside with? Click + to add additional childrenOpposing Party Work InformationOpposing Party Name of EmployerOpposing Party Employer Telephone numberOpposing Party Employer Address Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code How long has opposing party been there?Opposing Party Job titleOpposing Party Rate of PayHow many hours per week?YOUR DEMOGRAPHIC INFORMATIONPlease provide YOUR demographic information. GenderMaleFemaleRaceWhiteBlackAsianNative AmericanEthnicityHispanicNon-HispanicLanguageEnglishSpanishAre you a Veteran?YesNoAre you Disabled?YesNoIf yes, state your disabilityHow 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 the purpose of determining my eligibility to receive legal assistance from Lee County Legal Aid Society. 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, this application for assistance will be denied. No application is denied for reasons of race, sex, creed, color, religion, age, national origin, marital status, disability, or sexual orientation.Privacy* Accept I understand the information provided in this application will be treated as confidential. I understand the information I provide in the application will only be used to determine eligibility for services.Eligibility* Accept I understand this application is only a preliminary screening and eligibility is not guaranteed. Completing the application does not make me a client of Lee County Legal Aid Society and does not create an attorney-client relationship. I understand that I 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. I understand that it may take up to 3 weeks for final determination to be made.Signature*Type your name as your signatureDate of signature* 35014
