Client Application

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Client Application

Domestic Violence

Please fill out the form below to apply.

Personal Information

Name

Address

City/State/Zip

County

Home Phone

Work Phone

Employer

E-Mail

Date of Birth (MM/DD/YYYY)

Age

Sex

Male
Female

Veteran

Yes, I am a Veteran.
No, I am not a Veteran.

Disabled

Yes, I am Disabled.
No, I am not Disabled.

Migrant Worker

Yes, I am a Migrant Worker.
No, I am not a Migrant Worker.

Race

Marital Status

Single
Married
Divorced
Widowed/Widower

Spouses Name

Spouses Address

Household Occupancy

# of Adults Living in Home

# of Children Living in Home

Monthly Household Income

Employment

$ / Month

SS/SSI/SSD

$ / Month

AFDC

$ / Month

Retirement/Pension

$ / Month

Child Support

$ / Month

Unemployment

$ / Month

Other

$ / Month

Total Monthly Income

$ / Month

Assets Value

Checking Account

Savings Account

C.D.'s

Home

Real Estate

Stocks

Bonds

Auto

Other

Total Assets

Allowable Deductions

Child Care

Unreimbersed Medical Costs

Child Support

Alimony

Other

Total Deductions

Misc.

Have you spoken with another Legal Aid agency or Private Attorney regarding this matter?

Yes, I have spoken to someone.
No, I have not spoken to anyone.

If yes, please specify.

Please specify the type of legal dispute and names of the other party(s) involved.

Important Information


Dear Applicant:

Legal Aid of Manasota, Inc. is a not-for-profit organization created to respond to the continuing need for civil legal services to the poor of Sarasota and Manatee counties. Legal services are provided by private lawyers on a volunteer (pro bono) basis. Although the attorneys are not paid for their services, some costs will occur. These fees may include but are not limited to: the clerk, court reporters, sheriff and any witness that may be involved. Any fees for services are your responsibility!  The Courts have developed a system for indigent applicants to enter into a deferred payment agreement for court fees and other court related services. Indigent status is solely determined by the Court. FAILURE TO COMPLY WITH THE DEFERRED PAYMENT AGREEMENT MAY RESULT IN THE ENTRY OF A JUDGMENT AGAINST THE INDIGENT APPLICANT.

You have just completed an application for legal assistance from Legal Aid of Manasota, Inc. At this point your application has not been accepted. Your application must first be reviewed by our Executive Director to determine whether you qualify for assistance. Until you have been notified that your case has been accepted, Legal Aid of Manasota, Inc. will not take any legal action on your behalf and we will not advise you as to what action, if any, should be taken concerning your present problem. It is your responsibility to meet any immediate deadlines requiring a response.

Eligibility will be based on financial situation, case type, merit and your area of residence or case venue. Legal Aid handles civil matters only. Please remember that upon acceptance of your application, we can only attempt to refer you to a volunteer attorney. Therefore, we cannot guarantee the length of time it will take to place your case.

If at any time during the process you have a grievance, please contact the Executive Director in the Sarasota office.
If you move, are served with court papers, or if your financial situation changes before you receive a final referral, please call us immediately so that we may update your application. Failure to do so may result in denial of services.

Thank You,

Legal Aid of Manasota, Inc., Members and Staff

Retainer Agreement

I hereby authorize Legal Aid of Manasota, Inc. (LAMS), and any other attorney LAMS designates, to represent me with regard to my legal problem.


I understand that if the LAMS volunteer attorney agrees to take my case to court, I may be asked to pay litigation or transaction costs (such as fees for transcripts), BUT ONLY IF I AM FINANCIALLY ABLE TO PAY SUCH COSTS.

I understand that LAMS will not ask me to pay any attorney's fees for the services of a volunteer attorney.

I authorize the LAMS volunteer attorney to claim and collect from the opposing parties attorneys fees and litigation costs that the Judge may require the opposing parties to pay, so that LAMS can be reimbursed for costs and expenses paid on my behalf while handling my case.

I understand that LAMS is under no obligation to appeal my case if I should lose.

I agree to inform LAMS of any change in my address, telephone number, or financial situation while LAMS is assisting me.  LAMS will keep me reasonably informed as to my case.

I have the exclusive right to settle or otherwise dispose of the case.

I understand that LAMS may be required to disclose certain information to its funding sources.  The types of information currently subject to such disclosure are time records, this retainer agreement, client trust fund and eligibility records, and the client's name.

*Generally, LAMS will not provide a court reporter at any court hearings because of the limited financial resources of LAMS, unless I have been advised otherwise by my attorney.  If I want to fully preserve my right to appeal any adverse court decisions, I must hire a court reporter at my own expense to attend and transcribe the proceedings.

Please Read and Sign Below


I understand that there are no guarantees by Legal Aid of Manasota, Inc., or members thereof, for providing civil legal representation to me. All the information I have provided is correct to the best of my knowledge.

I further understand that if I withhold information on my application or about my case, I will be subject to immediate termination.

I authorize all information provided to be verified by Legal Aid of Manasota, Inc. and their staff. Furthermore, I hereby authorize Legal Aid to release information about my legal situation to private attorneys for referral purposes, including information that may be confidential in nature.

I have read all of the information above, and agree to the terms as stated.
The above information has been read to me, and I agree to the terms as stated.

Signature

Date