DuPage Bar Legal Aid Service
126 S. County Farm Rd., Wheaton, Illinois 60187-4597
Phone: (630) 653-6212 -- Fax: (630) 653-6317
e-mail: lasdupage@sbcglobal.net
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Application for Legal Assistance

To The Applicant:

To apply for assistance, you must FIRST call DuPage Bar Legal Aid Service at (630) 653-6212 between 9:00 a.m. and 2:00 p.m. for a screening. You will then receive an application number. You may then print this web page and use it to submit the required additional information for your request for assistance to the DuPage Bar Legal Aid Service.

The following information is needed to determine your eligibility for pro bono (without charge) representation through this office.

It is REQUIRED that you complete the entire application, submit the necessary verification, and sign and date the application.

The verification required is listed in bold type and enclosed in boxes throughout the form. Please send copies of the documentation requested. A written explanation will be needed if you are unable to provide any of the verification requested. YOUR APPLICATION WILL BE DENIED IF YOU FAIL TO SUBMIT VERIFICATION REQUESTED. SEND ONLY COPIES.

We must receive this information within 30 days or your file will be closed without notice.

To protect confidentiality, do not telephone our office about the status of your eligibility. You will be notified by mail of the decision in a timely manner.

Applicant's checklist
[ ] Filled in form completely.
[ ] Signed and dated form.
[ ] Enclosed copies of all verification.
[ ] Put in writing reasons for any
verification not enclosed.

ADDITIONAL SCREENING INFORMATION

(Please print or type.)

Last Name: ____________________ First Name: __________________ MI: ___
Application No.: _______________ (You received this during your initial phone contact.)
Maiden Name: ____________________ Driver's License No. _______________
Complete Address: __________________________________________________
Mailing Address: ____________________________________________________
Home Phone: ___________________ Alternate Phone: _________________

List all people who live at this residence (EVEN IF NOT RELATED):
Name Relationship Birth Date/Age Male/Female Income
_____________________ ______________ _____________ ( M / F ) $____________
_____________________ ______________ _____________ ( M / F ) $____________
_____________________ ______________ _____________ ( M / F ) $____________
_____________________ ______________ _____________ ( M / F ) $____________
_____________________ ______________ _____________ ( M / F ) $____________

Opposing party's full name: _________________________________________________
Date of birth: _______________ Age: _____ Relation to you: ______________________
Complete address: _____________________________________________________________
Employer/City: __________________________________________ Income $________
Occupation: _____________________ Other income: $_______ Source: _________________
Driver's License No.: _________________ Social Security No.: ________________
Opposing Attorney: _________________________________ City: ______________

Did you work in the last 2 years? ( Yes / No ) Occupation: __________________
Are you currently working? ( Yes / No ) Employed by: ________________
Current occupation: ______________________ How often paid? ______________
Do you receive child support? ( Yes / No ) If so, how much monthly? _______
Do you receive maintenance? ( Yes / No ) If so, how much monthly? _______

List all other source(s) and amount(s) of income you receive:
(For example: public benefits, additional jobs, unemployment income, family/friends support, workers compensation, etc.)
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________

YOU MUST SUBMIT ALL OF THE FOLLOWING VERIFICATION THAT PERTAINS TO YOUR HOUSEHOLD INCOME.
  1. VERIFY YOUR UNEMPLOYMENT AND HOW YOU PAY YOUR EXPENSES.
  2. VERIFY ALL PUBLIC BENEFITS.
  3. VERIFY YOUR EMPLOYMENT INCOME BY SENDING 3 MONTHS OF PAYSTUBS/PAYROLL RECORDS AND MOST RECENT TAX RETURNS
    (Including any supporting tax schedules).
  4. VERIFY ALL INCOME OF UNRELATED MEMBER(S) OF THE HOUSEHOLD (Roommates).
  5. VERIFY SPOUSE'S INCOME IF LIVING IN THE HOME.
  6. SEND A LETTER FROM FAMILY OR FRIENDS WHO SUPPORT YOU FINANCIALLY.

Minor children / dependents not currently living with you:

NAME RELATION D.O.B. / AGE RESIDENCE
___________________ ___________________ ___________________ ___________________
___________________ ___________________ ___________________ ___________________
___________________ ___________________ ___________________ ___________________

Do you pay child support? ( Yes / No ) If so, how much monthly? ________
Do you pay for day care? ( Yes / No ) If so, how much monthly? ________
Do you pay maintenance? ( Yes / No ) If so, how much monthly? ________

List your basic monthly expenses:

$ ________ /Mo. Rent / mortgage payment $ ________ /Mo. Auto payments
$ ________ /Mo. Real estate taxes $ ________ /Mo. Doctor
$ ________ /Mo. Insurance $ ________ /Mo. Dentist
$ ________ /Mo. Utilities $ ________ /Mo. Clothing
$ ________ /Mo. Food $ ________ /Mo. Child care
$ ________ /Mo. Transportation expense $ ________ /Mo. Miscellaneous

Do you own your own home / other real estate? ( Yes / No )
If yes, you MUST answer ALL of the following:

__________ Date of purchase $ ________ Fair market value
__________ Last appraisal date $ ________ Mortgage balance

YOU MUST SUBMIT ALL OF THE FOLLOWING VERIFICATION THAT PERTAINS TO YOUR HOME / RESIDENCE.
  1. IF YOUR HOME HAS NOT BEEN APPRAISED IN THE LAST 12 MONTHS, YOU MUST SUBMIT A COPY OF A WRITTEN APPRAISAL. (Real estate agencies typically will do appraisals free of charge.)
  2. SEND A COPY OF ANY FORECLOSURE NOTICES, IF APPLICABLE.
  3. IF RENTING, SEND A COPY OF YOUR LEASE, ELECTRIC BILL, AND PHONE BILL.

List and describe all pending lawsuits or claims in which you are a party. State whether you have an attorney for the matter(s), and what is the expected outcome of the suit.
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________

Bank accounts:
Savings Checking
Bank: ______________________ Bank: ______________________
Names on Account: __________ Names on Account: __________
___________________________ ___________________________
Account # __________________ Account # __________________
Balance: $ _________________ Balance: $ _________________

Do you have a motor vehicle? ( Yes / No ) If so,
Make ________________ Model ______________ Year ______ Value $_________

List any other assets and their values (including employment benefits such as retirement,
IRA, or 401K accounts for you or your spouse: _________________________________
________________________________________________________________________
________________________________________________________________________

State your charge accounts:
Company: ___________________ Balance: $_________ Payments: $________ / Mo.
Company: ___________________ Balance: $_________ Payments: $________ / Mo.
Company: ___________________ Balance: $_________ Payments: $________ / Mo.
Company: ___________________ Balance: $_________ Payments: $________ / Mo.

Document any loan applications you made with financial institutions since January 1, 1994.
Name / address of institution: _____________________________________________
Date of application: __________ Amount requested: $_________

Please attach a copy of the financial statement.

Describe your legal problem: _______________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Is there domestic violence in regards to this matter? ( Yes / No )

If this is a divorce or post-divorce matter, complete the following:
Date and place of marriage: ________________________________________________
Date and place of legal separation / divorce: ___________________________________

YOU MUST SUBMIT ALL OF THE FOLLOWING VERIFICATION THAT PERTAINS TO YOUR LEGAL MATTER.
  1. COPIES OF ALL COURT DOCUMENT(S) (i.e. Judgements, orders, etc.) OR ANY OTHER RELATED DOCUMENTS.
  2. IF THIS IS A POST-DECREE CHILD CUSTODY MODIFICATION ORDER, YOU MUST SUBMIT A REPORT FROM A CHILD CARE PROFESSIONAL (i.e. Child psychiatrist, DCFS, etc.) WHO IS ABLE TO TESTIFY IN COURT.
    (It is your responsibility to pay any fees or court costs required in obtaining this report and for the professional to testify.)

I am a U. S. citizen. ( Yes / No )

I was born in: City _________________ State/Country __________

Signature: _________________________________ Date: ____________

OTHER VERIFICATION:
  1. VERIFICATION OF U.S. RESIDENCY STATUS IF NOT A U.S. CITIZEN.
  2. COPY OF DRIVER'S LICENSE.

The undersigned declares under penalty of perjury that the answers to the foregoing financial information questions as well as any and all attachments are true and correct as of the date of signature.

Signature: _________________________________ Date: ____________