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Application for Legal Services
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Name
*
First Name
Middle Name
Last Name
Address:
Street Address
Street Address Line 2
City
Please Select
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Alaska
Arizona
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California
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Connecticut
Delaware
District of Columbia
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Louisiana
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Maryland
Massachusetts
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New Hampshire
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Ohio
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Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
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Washington
West Virginia
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State
Zip Code
Phone Number:
-
Area Code
Phone Number
E-mail
Date of Birth
*
Please select a month
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Month
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1
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Day
Please select a year
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1937
1936
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1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Year
Social Security Number (Last 4)
*
Driver's License/ID Number
Driver's License/ID State
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
Veteran
*
Yes
No
Gender
*
Male
Female
Transgender
Marital Status
*
Single
Married
Divorced
Widowed
Race
*
African American
Caucasian
Hispanic
Asian
Other
Citizenship
*
US Citizen
Legal Resident
Undocumented
Disability
*
Mental Disability
Physical Disability
Mental and Physical Disability
Not Disabled
Do any of the following apply to you?
*
Victim of Domestic Violence
Victim of Other Crime
Migrant Worker
Person with Terminal Illness
Homeless
None of the Above
How did you hear about Beacon Law?
*
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Dependents
Do you have any people living with you that depend on you for financial support?
*
Yes
No
Household Size
*
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List the name, age and relationship to you for each person living with you that you support.
*
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Monthly Household Income
Please enter total income for all contributing members of your household. A household consists of the people living with you who depend on you for financial support or are supporting you.
Work Wages
*
Total per month
Unemployment
*
Total per month
Food Stamps/SNAP
*
Total per month
Public Housing Assistance
*
Total per month
Child/Spousal Support
*
Total per month - Do not enter support you pay
SSI/SSDI/VA Disability
*
Total per month
Retirement/Pension
*
Total per month
Total Monthly Income
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Assets
Do you own more than one house?
*
Yes
No
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Assets
What is the current value of your additional house, minus any outstanding mortgage?
*
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Assets
Do you own more than one vehicle?
*
Yes
No
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What is the current value of your additional vehicles, minus any outstanding loan balance?
*
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Assets
Do you have any savings accounts, stocks, bonds, or other property?
*
Yes
No
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What is the current value of your savings accounts, stocks, bonds, or other property?
*
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Monthly Expenses
Mortgage/Rent
*
Utilities
*
Gas/Water/Electricity/Phone/Cable
Food
*
Child Care
*
Car Payment/ Insurance
*
Gas/Bus Fare/Tolls
*
Attorney's Fees
*
Health/Life Insurance Premiums
*
Medical Expenses
*
copays, prescriptions, etc.
Clothing/Laundry
*
Other Misc. Personal Expenses
*
Total Monthly Expenses
FPG %
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Authorization for Release of Information
It is often the case that applicants and clients of Beacon Law are not able to maintain consistent means of communication. Should if be necessary, you may authorize employees of Beacon Law to communicate with a designated friend or relative regarding your case. If you would like to authorize us to speak to another individual regarding your case, please complete the information below. This authorization is revocable at any time by written or verbal notice and does not constitute a violation of attorney/client privilege or breach of confidentiality.
Name
First Name
Last Name
Relationship to you
Address
Street Address
Street Address Line 2
City
Please Select
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
State
Zip Code
Phone Number
-
Area Code
Phone Number
Email
example@example.com
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Acknowledgement
Beacon Law will perform a conflicts check to determine if we are able to represent you. If an internal conflict exists, we will refer you to another agency for possible assistance. If no conflict is found, your completed application will be reviewed to determine if representation is appropriate, determine the scope of representation and assignment to the appropriate case handler. The case review and assignment process can take up to 6 weeks depending on current volume, though some cases will be approved and assigned sooner. You will be contacted by your case handler as soon as your case has been assigned. By submitting this application, you certify that you are the named applicant and all the information contained is true and correct to the best of your knowledge. The information submitted in this application is confidential and Beacon Law will not discuss it with anyone without your written consent. At this time there is no Attorney/Client Relationship. We will maintain a digital copy of this application for statistical and conflict check purposes.
To agree to the acknowledgment above, check the box below.
*
I, the above named applicant, certify that the information contained in this application is true and correct to the best of my knowledge and Beacon Law has my authorization to contact any additional contact person submitted with this application regarding my application and case.
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