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Consumer Intake

Please use the “Back” and “Next” buttons at the bottom of the form.

Section A: Basic Information 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 delete from our systems the information in the following sections. * indicates a required field.

WhiteBlackHisp./LatinoAsianPacific Island.Native Amer.Biracial/MultiracialPrefer Not to AnswerOther
FemaleMaleGender NonconformingPrefer Not to AnswerOther:
Section A: Basic Information 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 option 2.

Who is on the other side of your case?* (Ex: name of company, mortgage lender, person, etc.)

Date of Birth (Only fill out this field if the other party is a real person)






Section B: Household Income Legal Aid generally serves individuals whose household income is at or below 200% of the Federal Poverty Guidelines. For some types of cases, we may serve individuals whose household income is up to 300% of the Federal Poverty Guidelines. Please provide the following basic information about your household income so that we can determine whether you are eligible for our services. Be sure to include all income that ANY member of your household is receiving. If we are unable to assist you for any reason, this information in this section will be deleted from our system.

Please provide your best estimate(s) if you are not sure. For example, if your paycheck changes based on the hours you work each week, try to provide an estimate of your average weekly or monthly income.

Type of Income*
Amount
Frequency
Type of Income
Amount
Frequency
Type of Income
Amount
Frequency
Type of Income
Amount
Frequency
Type of Income
Amount
Frequency

Tip: If neither you nor anyone in your household receives any form of income, please select the option that says “My household has zero income” in the first drop-down box.

If you are unsure about how to define your income or want to give us additional information, please use the box below.
Section C: Information about Your Legal Matter
Please provide the additional information below describing your legal matter. If we are unable to provide you with legal representation on this matter for any reason, the information in this section will be deleted from our system.

Type of consumer matter:

Debt CollectionForeclosureAuto Insurance SubrogationStructured Settlement Transfer
Debt Collection

1. What company or companies say that you owe them money? 
2. Have you been sued on this debt? YesNo
a. What is your court case number (if known)?

3. Do you have any notices or court papers related to this problem? YesNo

a. How did you receive these papers?

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. Do you believe this debt is the result of identity theft? YesNo
Please explain.

6. Do you believe this debt is the result of someone else using your account? YesNo
a. Please provide the person’s name and date of birth.

7. Do you disagree with the amount they say you owe? YesNo
Please explain.

8. When did you last make any payments or use the account?

9. 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. Do you have any bank accounts? YesNo
a. Approximately how much money do you have in the bank?

b. Are any of your bank accounts joint accounts? YesNo

i. Who is the other person on your joint account(s)? Please list their name(s) and their relationship to you.

5. Do you own a car, a home, or other major assets? YesNo

a. What assets do you own? Please describe.

b. Are these assets currently mortgaged or financed, or have they been paid off?

6. Can you afford to make any payments toward this debt? YesNo

a. What do you think you can afford?

7. What else should we know about this debt? (Ex: Any concerns with identity theft, issues with how you got the account, medical and/or financial hardship preventing you from being able to pay, etc.)

8. What is your goal? (Ex: get an affordable payment plan, dispute that you owe the debt, stop garnishment, etc.)

9. Is there anything else we should know about your case?

Foreclosure
Home
1. Have you been sued for foreclosure? YesNoI don't know
a. What is your court case number?
b. Do you have an "Initial Conference" (the first court date in the case) coming up? YesNoI don't know
Click here for a document that explains what to do on your first court date.
a. Have you received any notices on D.C. Government letterhead talking about foreclosure and mediation? YesNo

2. What is the address of the home that is in danger of foreclosure?
3. Do you live in the home facing foreclosure? YesNo
4. 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.
5. Do you have any tenants? YesNo
Please provide the names and dates of birth of all tenants.
6. Who owns the home (i.e. who is on the deed)?

7. Is your home part of a condominium or homeowners’ association? YesNo
What is your current monthly condo or HOA fee?

Are you behind on your condo or HOA fees? YesNo


8. Do you own any other properties? YesNo
a. Please provide the address(es) for any other property/properties that you own.
Mortgage
1. Who is your mortgage company?


2. Please provide basic information about the loan at issue:

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


    When?

3. Do you currently have any other mortgages or lines of credit on the property? YesNo

Please provide the name of the lender and estimated balance for the other loan(s).


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 explain:

Goals
1. Do you want to keep the home, sell it (is the property already listed?), or do something else with it?

2. Is there anything else we should know about your case?

Auto Insurance Subrogation


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
a. What is your court case number?
2. How did you find out about the case? 3. Has your driver’s license been suspended? YesNo
B. The Accident
1. Do you recognize the accident at issue? YesNo

2. 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.)

3. Who do you think was at fault and why? (If you think more than one person was at fault, please explain.)

4. Did the police or other first responders come, or were there any other witnesses? YesNo
a. Please explain.


5. Have you been interviewed by anyone about the accident (for example, the insurance company)? YesNo
a. Please state who you spoke with and describe what was said.
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
a. Who was the owner (for example, if you were driving a friend or family member’s car or an employer’s vehicle)? b. Did the owner have insurance at the time of the accident? YesNoNot Sure

D. Goal
1. Please describe your goal in resolving this case (for example, get affordable payment plan, get driver’s license back, dispute liability for accident, etc.)

2. Is there anything else we should know about your case?

Structured Settlement Transfer


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. Has the company filed paperwork asking the court to approve the transfer? YesNoNot Sure
a. What is your court case number?


5. Did the company solicit you to do the transfer, or did you contact them? Please describe.

6. Did you negotiate with the company or shop around to get a better deal? YesNo
a. Please explain.


7. Please describe your understanding of the proposed transfer (for example, what you are selling and how much you are getting in return).
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
a. Describe any prior transfers (include dates and court case numbers, if any; the company that did the prior transfer; and note whether the prior transfers were approved)

Financial information
1. Please list all of your sources of income (including all public benefits) and the amount/frequency






2. Do you have any dependents? YesNo
a. Please list your dependents and their relation to you.

3. Do you depend on anyone else financially? YesNo
a. Please explain.
Is there anything else we should know about your case?
Section D: Documents
If you have documents related to your issue, it can be helpful to see them to better understand your legal problem. Here are the the kinds of documents that could be helpful in your case.

Debt Collection
  • Collection Notices
  • Correspondence with debt collector

Auto Insurance Subrogation
  • Correspondence from the other side
  • Police Report
  • Insurance Information( this could be proof od
  • any proof of insurance documentation that you have (for example, a Declarations Page showing your insurance coverage at the time)

Foreclosure
  • Recent monthly statement
  • .Recent correspondence from your mortgage company
  • Any statements/bills that you have not already uploaded

Structured Settlement
  • Documents relating to the proposed transfer (petition, disclosure statements, application form)
  • Documents relating to your original annuity and the underlying case
  • Documents relating to any prior transfers

Please let us know if you have any documents, and if so, how you would like to provide them to us.
I have no documents.I have documents and will drop them off in person at Legal Aid (1331 H Street,NW, Suite 350, Washington, DC 20005; M 9am-6pm, T-F 9am-5pm)I have documents and will email them to onlineintake@legalaiddc.org. Please include your full name in the subject.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 the documents to the following address: Legal Aid Society of the District of Columbia Attn: Online Intake 1331 H St NW, Suite 350 Washington, DC 20005I can upload some of my documents now
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