For screening on:
 
Wednesday, August 19, 2020 between 9:00 a.m. to 12:00 p.m.
 
please complete the following form.
 
Please note that most of the fields are required.  If the information does not apply to you, just write none or n/a.  Thanks.   
     
 
Please type the date that appears above.*
 
Franklin County Legal Services (FCLS) is a nonprofit agency located in Chambersburg, Pennsylvania that provides free help in civil legal problems to low-income individuals.*
 
I understand and agree.   
 
During the above time, a screening for any conflict of interest and income eligibility will take place first. Those applicants still eligible will then speak to a FCLS attorney about their legal concern.*
 
I understand and agree.   
 
In most situations, we will be able to tell you on the date above if you are eligible for any of our programs. If you are eligible, we will give you detailed information about the next step.*
 
I understand and agree.   
 
FCLS can provide services only to persons whom have met eligibility requirements which are based on household income/assets, conflict of interest checks, and criteria established by FCLS to best utilize the limited resources available to the agency.*
 
I understand and agree.   
 
FCLS provides its immigration legal services only to persons living in the Pennsylvania counties of Franklin, Fulton, Adams, Cumberland, Perry, Juniata, and Huntingdon (or had lived in those counties prior to detention).*
 
I understand and agree.   
 
FCLS prioritizes services to persons for whom a civil legal problem is affecting a basic human need.*
 
I understand and agree.   
 
While FCLS provides free services to hundreds of persons each year, it is not able to help everyone.*
 
I understand and agree.   
 
Persons may be determined ineligible after undergoing a lengthy application process. Even with this information, you are choosing to proceed with this application to be screened for eligibility.*
 
I understand and agree.   
 
FCLS appreciates the time that applicants give to this assessment, and we hope we can help.*
 
I understand and agree.   
 
You will likely need to refer to documents describing your household's income/assets and your legal issue to complete this application. You will also need to have them with you during your screening time above. *
 
I understand and agree.   
 
After you submit this application, you will receive an email prior to the above date with a copy of this application and more
information about the screening.*
 
I understand and agree.   
 
When speaking with or meeting with FCLS, children are not permitted to be nearby where they can overhear the conversation. Childcare must be arranged.*
 
I understand and agree.   
 
FCLS may ask you to distance yourself from others while speaking with us so that confidentiality can be maintained.*
 
I understand and agree.   
 
If FCLS is unable to reach you on the above date/time, this application will not be saved and you will need to re-apply if you still need assistance.*
 
I understand and agree.   
 
If you do not complete the application process (which ends by speaking with an attorney) or you are determined ineligible prior to speaking with an attorney, none of the information you submit will be saved by FCLS.*
 
I understand and agree.   
 
Speaking with FCLS for eligibility screening does not create an Attorney-Client relationship between you and FCLS. If FCLS decides to represent you, a formal Retainer (Representation) Agreement will be signed.*
 
I understand and agree.   
 
You are completely responsible for your legal matter (including any deadlines, hearings etc.) until a Retainer (Representation) Agreement is signed. *
 
I understand and agree.   
 
You are always free to seek other legal services/representation outside of FCLS at any time in your involvement with us.*
 
I understand and agree.   
 
For persons whom FCLS has met with/spoken with and have NOT signed a formal Retainer (Representation) Agreement: If you do not return phone calls, keep appts., or make a reasonable effort to resolve your legal problem, you may be required to re-apply.*
 
I understand and agree.   
 
All of the information that you provide on this application will remain confidential except as provided in the following 3 paragraphs.*
 
I understand and agree.   
 
FCLS may share all information about your case with any attorney recruited by FCLS to provide you with legal assistance on a pro bono (no fee) basis.*
 
I understand and agree.   
 
FCLS may share all information about your case with any interpreter/translator needed in your case.*
 
I understand and agree.   
 
FCLS may include information about you and your case in fundraising appeals and other publications as long as other people cannot tell that it is about you.*
 
I understand and agree.   
First Name*
Middle Name*
Last Name*
Previous names used in your lifetime (maiden name, previous married name etc.)*
   
 Street Address* 
City*
State*
Zip Code*
Email Address*
Telephone Number*
Please provide an alternate phone number if we are unable to reach you at the above #*
Do you give permission for us to contact you (including recording voice messages, sending written messages or mail which may contain detailed information about your legal matter) by ALL of the above methods?* Yes   No   
IF NO, please state which methods we should NOT use to contact you*
   
County*
Township or Borough*
School District*
Date of Birth*
Preferred Language*
Country of Birth*
Country of Nationality*
Alien Number*
   
Have you been a victim of domestic violence within the past 5 years?* Yes   No   
Have you ever been incarcerated?* Yes   No   
Are you disabled?* Yes   No   
Do you have a mental health disability?* Yes   No   
   
Does anyone in your household own any real estate other than the home in which they live?* Yes   No   
Does anyone in your household own a motorcycle, 4-wheeler, RV, snowmobile, boat, or off-road vehicle?* Yes   No   
How much money do you have (bank accounts, cash, tax refund, CDs, stocks, bonds etc.)? Do NOT subtract upcoming bills first.*
   
What is your age?*
   
What is your gross monthly income?*
What is your income source(s)?*
   
Please list ALL persons living with you under Persons 1-5 below. How many people live under your roof including you?*
   
Person 1 living with you - Name*
Person 1 living with you - Relationship to you *
Person 1 living with you - Age*
Person 1 living with you - Gross Monthly Income*
Person 1 living with you - Income source*
Person 2 living with you - Name*
   
Person 2 living with you - Relationship to you*
Person 2 living with you - Age*
Person 2 living with you - Gross Monthly Income*
Person 2 living with you - Income source*
Person 3 living with you - Name*
   
Person 3 living with you - Relationship to you*
Person 3 living with you - Age*
Person 3 living with you - Gross Monthly Income*
Person 3 living with you - Income source*
Person 4 living with you - Name*
   
Person 4 living with you - Relationship to you*
Person 4 living with you - Age*
Person 4 living with you - Gross Monthly Income*
Person 4 living with you - Income source*
Person 5 living with you - Name*
   
Person 5 living with you - Relationship to you*
Person 5 living with you - Age*
Person 5 living with you - Gross Monthly Income*
Person 5 living with you - Income source*
   
If there are more than 6 people living under your roof, please list the additional persons. Please provide name, relationship to you, age, gross monthly income, and income source of each person.*
   
How many veterans live in your home?*
   
First Name of Adverse Party (the party you are having the legal dispute or issue with).*
Middle Name of Adverse Party*
Last Name of Adverse Party*
Previous names used by Adverse Party in his/her lifetime (maiden name, previous married name etc.)*
   
Address of Adverse Party*
Phone Number of Adverse Party*
County of Adverse Party*
   
Date of Birth of Adverse Party*
   
Does the Adverse Party have an attorney?*
If the Adverse Party has an attorney, what is the name of the attorney?*
   
Do you have children with the Adverse Party? If yes, please list them under Child 1-4 below.* Yes   No   
   
Child 1 - Name*
Child 1 - Date of Birth*
   
Child 2 - Name*
Child 2 - Date of Birth*
   
Child 3 - Name*
Child 3 - Date of Birth*
   
Child 4 - Name*
Child 4 - Date of Birth*
   
Giving specific dates and facts, please describe your legal issue from beginning to present.*
Additional space for above box
Additional space for above box
   
Are there any upcoming deadlines or hearings in this matter?* Yes   No   
If there is a deadline or hearing, what is the date of it?*
If there is a deadline or hearing, please describe it.*
   
What would you like Franklin County Legal Services to do to help you with this matter?*
   
Please upload any document that will help us to understand your legal problem.
   
All of the information that I provided on this application is true to the best of my knowledge. * I understand and agree.   
   
I understand that clicking SUBMIT below is the same as physically signing this application.* I understand and agree.   
   
PLEASE only click submit
ONE TIME.