Montana Legal Services Association
Application for Assistance for
AmericanIndianTrustLand
Instructions: To find out if this application is right for you, please see “American Indian Trust Land: How to Apply for Help to Draft a Will.”
To apply for services please fill out this application completely. If a question does not apply to you, please write N/A (not applicable) in the blank. Accurate and current information is important. When you have completed the entire form, please sign and date this cover sheet and return the application to us at the address below. We will contact you after reviewing your application.
*In order to avoid a delay in processing your application, please complete all sections of this form*
I, , am an applicant for civil legal
assistance from Montana Legal Services Association.
By placing my signature below, I understand I am verifying that the information I have
providedon the attached Application for Assistance is true and accurate. I further
verify that I am a □Citizen or □Permanent Legal Resident of the United States.
Date Signature
Send completed application to: MONTANA LEGAL SERVICES ASSOCIATION
Attn: Bernadette O’Donnell
PO Box 3093
Billings, MT59103-3093
Or fax to:(406) 252-6055
If you need assistance in completing this application, or would like to apply over the phone, please call the MontanaLegal Services Association’s HelpLine Number at:
1-800-666-6899
1. Name
First MI Last
2. Address
City State Zip
3. Do you □ rent □ own home □ live with relatives
□ live with friends □ other
4. Your Home Phone Number:
5. Your Work Phone Number:
6. E-mail Address:
7. Is it safe to contact you at the above addresses and phone numbers?
8. Alternate contact information
9. Reason you are seeking legal services: □ Family Law with children □ Family Law without children
□ Landlord/Tenant □ Debt □ Name Change □ Other:
10. Are you currently represented by an attorney?
11. Household Size: How many people live in your household? Adults Children
Please list each member of your household by name, their relationship to you (ex: “boyfriend,” “son,” etc).
Attach additional pages if necessary.
Full Name / Relationship / Age / Do you financially support this person?□ Yes □ No
□ Yes □ No
□ Yes □ No
□ Yes □ No
12. Household Income: (include information on each person with income listed in your household)
Before Taxes / Employment / Unemploy-ment / SSI / SocialSecurity / Child Support / Welfare/
TANF / VA / Other
(specify)
you / $______
Paid □ hourly □ weekly
□ bi-weekly □ monthly
□ other: / $ / $ / $ / $ / $ / $ / $
Other household member / $______
Paid □ hourly □ weekly
□ bi-weekly □ monthly
□ other: / $ / $ / $ / $ / $ / $ / $
Other household member / $______
Paid □ hourly □ weekly
□ bi-weekly □ monthly
□ other: / $ / $ / $ / $ / $ / $ / $
Do you receive Food Stamps?□ Yes □ No
13. Assets:
Total assets of everyone in household: Cash $ Checking $ Savings $ Other $
Do you own more than 1 house?□ Yes □ No
If yes, Amount paid for 2nd house $ Amount owing on 2nd house $
Does anyone in your household own land or real estate? (Exclude property you live on)□ Yes □ No
Description:
Amount Paid $Amount Owing $
Do you or anyone in your household own one or more vehicles? □ Yes □ No If yes, please list below:
Make Model Year Current Value $ Amount Owing $
Make Model Year Current Value $ Amount Owing $
Make Model Year Current Value $ Amount Owing $
Other Assets: (i.e. motorcycle, recreation vehicles, watercraft, guns, horses, etc.)
Description: Amount Paid $ Amount Owing $
Description: Amount Paid $ Amount Owing $ Description: Amount Paid $ Amount Owing $
14. Opposing Party Information: We must have this information before we can provide services.
Name:Address:
Phone (if known):
Does Opposing Party have an attorney?□ Yes □ No
If yes, what is that attorney’s name?
Has this person ever gone by any othernames? □ Yes □ No
If yes, list other names(s) (including maiden name)
Have you been served with any paperwork? □ Yes □ No
If yes, when were you served?
Please send us copies of papers you were served.
15. Statistical Information (Needed by funding sources. Does not determine eligibility for services):
Date of Birth: Social Security Number: Sex: □ Male □ Female Marital Status: □ Married □ Divorced □ Separated □ Single □ Other
Have you ever gone by any other names (s) or contacted us using any other names?
If yes, please indicate what names(s):
Race:□ White □ Hispanic □ African American □ Asian or Pacific Islander □ Multi-cultural
□ Native American / Tribe □ Other
Language:□ English □ Spanish □ Russian □ Other
How did you hear about Montana Legal Services Association:□ Friend/Relative □ Prior Use
□ Court □ Other Social Agency □ montanalawhelp.org □ Other
Do you have any federal tax issues with the IRS □ Yes □ No
(need not be connected with the reason for this application)
If yes, please explain
16. Description of Problem: