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Please provide the following basic information, which will be used to perform a conflicts check. If we are unable to assist you based on this information, we will not review and will not enter into our system any information from the following sections. * indicates a required field.
By applying for legal assistance online you are agreeing to be contacted by all methods. If you prefer not to be contacted by these methods please call the intake line at 202-628-1161 by pressing 1 and then 2.
Address Line 2 (Apartment/suite number, unit)
City* State* AKALARAZCACOCTDCDEFLGAGUHIIAIDILINKSKYLAMAMDMEMHMIMNMOMSMTNCNDNENHNJNMNVNYOHOKORPAPRPWRISCSDTNTXUTVAVIVTWAWIWVWY Zip Code* Ward 12345678
Phone* (Please enter in this format: xxx-xxx-xxxx.)
Alternate Phone (Please enter in this format: xxx-xxx-xxxx.)
Date of Birth* (mm/dd/yyyy)
Who lives with you? Please list each household member’s name and date of birth.* (If you live alone, you can write “No one.”)
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Please provide the following information about your household income, which will be used to determine if you are eligible for our services. Please include all income that any member of your household receives. If you do not know exact figures, please provide your best estimate. For example, if your paycheck changes based on the hours you work each week, try to estimate your average weekly or monthly income. If we are not able to help you further based on your household income, the information in this section will not be entered into our system.
Please provide the additional information below describing your legal matter. If you have multiple issues, please check all boxes that apply.
If you need to return to an earlier part of the form, please use the “Back” button below instead of your browser’s “Back” button.
Type of consumer matter:
Debt Collection and/or BankruptcyForeclosureAuto Insurance SubrogationStructured Settlement Transfer
3. Do you have any notices or court papers related to this problem? YesNo
4. Have you had any contact with the company suing you or their attorney? YesNo
a. What was said?
b. Did you agree to a payment plan or discuss payment arrangements?
5. Have you been harassed by debt collectors about this debt? YesNo
6. Do you believe this debt is the result of identity theft? YesNo
7. Do you believe this debt is the result of someone else using your account? YesNo
8. Do you disagree with the amount they say you owe? YesNo
9. When did you last make any payments or use the account?
10. What caused you to fall behind on payments?
Detailed income and financial information
1. What is your gross income? Please note amount and frequency.
2. What is your net income?
3. What is the source of your income? Ex: employment, Social Security, benefits (Food Stamps, etc.)
4. What are your approximate monthly expenses (ex. rent, food, phone, utilities, childcare, etc.)? Provide a breakdown of type and amount if possible.
5. Do you have any bank accounts? YesNo
5. Do you own a car, a home, or other major assets? YesNo
7. Can you afford to make any payments toward this debt? YesNo
8. Do you expect you will have to take out more debt in the foreseeable future to make ends meet? YesNo
9. What else should we know about this debt? (Ex: Any issues with how you got the account, medical and/or financial hardship preventing you from being able to pay, etc.)
10. What is your goal? (Ex: get an affordable payment plan, dispute that you owe the debt, stop garnishment, etc.)
11. Are you interested in exploring bankruptcy as an option? YesNo
12. Is there anything else we should know about your case?
2. Do you have any deadlines coming up? Note: If you already described this deadline to us earlier in the intake, you do not need to do so again.
3. What is the address of the home that is in danger of foreclosure?
4. Do you live in the home facing foreclosure? YesNo
5. Who else lives there?
Please enter names and dates of birth, if known, of anyone else living there. This information is required for conflict check purposes.
6. Do you have any tenants? YesNo
7. Who owns the home (i.e. who is on the deed)?
8. Is your home part of a condominium or homeowners’ association? YesNo
9. Do you own any other properties? YesNo
a. Who is the named borrower on the loan?
b. Please indicate if your mortgage is any of the following types of loans: FHAFannie MaeFreddie MacNot sure
c. What is your current monthly mortgage payment? Even if you are not currently making payments, please provide an estimate of what your payment was before you stopped making payments.
d. When was the last time you made a payment on the mortgage? Please provide an estimate if you are not sure.
e. What caused you to fall behind on the payments?
f. Have you ever received a loan modification? YesNo
3. Do you currently have any other mortgages or lines of credit on the property? YesNo
Detailed income information
1. For each person in your household (including yourself), please list their gross income (amount and frequency) and the source.
2. Are you able to document all of the income in the household (through paystubs, benefits letters, tax returns, etc.)? YesNo
3. Is any income expected to change? YesNo
Please fill out the below questions if you were involved in an auto accident and the other driver’s insurance company is demanding money/reimbursement from you because they claim you were at fault. If this does not describe your situation, please call Legal Aid’s intake line at 202-628-1161.
A. Court Case
1. Have you been sued by the other driver’s insurance company? YesNo
2. How did you find out about the case?
3. Has your driver’s license been suspended? YesNo
B. The Accident
1. Please describe what you remember about the accident (if possible include the date, location, who was driving, who else was in the car, and what happened.)
2. Who do you think was at fault and why? (If you think more than one person was at fault, please explain.)
3. Did the police or other first responders come, or were there any other witnesses? YesNo
4. Have you been interviewed by anyone about the accident (for example, the insurance company)? YesNo
C. Insurance and Vehicle Information
1. Did you have auto insurance at the time of the accident? YesNo
2. Were you the owner of the vehicle involved in the accident? YesNo
1. Please describe your goal in resolving this case (for example, get affordable payment plan, get driver’s license back, dispute whose fault the acciddent was, etc.)
2. Is there anything else we should know about your case?
Please fill out the below questions if you have a structured settlement annuity and are in the process of selling your right to future payments in exchange for lump sum cash now. If this does not describe your situation, please go back and select another type of case, or call Legal Aid’s intake line at 202-628-1161.
A. Proposed Transfer
1. What is the name of the company proposing to purchase your structured settlement annuity payments?
2. How much money are you trying to get paid for the transfer?
3. Please explain why you need the money from the transfer.
4. Did the company reach out to you to do the deal? Or, did you reach out to them? Please describe.
5. Did you negotiate with the company or shop around to get a better deal? YesNo
6. Please describe your understanding of the proposed transfer (for example, what you are selling and how much you are getting in return).
7. Has the company filed paperwork asking the court to approve the transfer? YesNoNot Sure
Background on Your Structured Settlement Annuity
1. Please describe the underlying case that resulted in you getting an annuity (what type of case was it, where was it filed, when did it settle, etc.)
2. What was the case name and case number?
3. Please describe the current structure of your annuity payments (for example, describe any monthly amounts or lump sums that you are supposed to receive).
4. Have you ever tried to transfer your annuity payments before now? YesNo
1. Please list all of your sources of income (including all public benefits) and the amount/frequency
2. Do you have any dependents? YesNo
3. Do you depend on anyone else financially? YesNo
Is there anything else we should know about your case?
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If you have documents related to your issue, it can be helpful to us to see them to better understand your legal problem. Here are the kinds of documents that could be helpful in your case:
Auto Insurance Subrogation
I have no documents.I can upload some of my documents now.I have documents and will email them to firstname.lastname@example.org. Please include your full name in the subject.I have documents and will fax them to Legal Aid at 202-727-2132. Please put to the attention of Online Intake on the cover sheet.I have documents and will mail them to Legal Aid. Please include your full name on the envelope and on the cover sheet (if any).
Please send copies of the documents not originals to the following address:
Legal Aid Society of the District of Columbia
Attn: Online Intake
1331 H St NW, Suite 350
Washington, DC 20005