FAMILY COURT ELIGIBILITY SCREENING FORM

Have you been referred to our program from Erie County Family Court? *

Yes

No

Type of case: *

Relationship to Child

First Name *

Last Name *

Street Address *

Address Line 2

City *

State *

Zip Code *

Phone Number *

Email Address

Date of Birth * +

Country of Birth

Are you a Veteran?

EMPLOYMENT AND PUBLIC ASSISTANCE

Do you receive any public assistance? (Check all that apply)

If you are receiving Food Stamps and/or Medicaid, please provide your Benefit ID number (located on your Benefit Card)

Are you employed/receiving SSD? *

Yes

No

How many in household? (Including yourself) *

Average Income Per Week (Net) *

Other Income Amounts Per Week (Including Child Support, Alimony, Rental Income, Pensions, Annuities)

Total Amount in Checking and Savings Account(s) *

MONTHLY EXPENSES

Do you rent or own your home? *

Rent/Mortgage

Car Payment

Child Care

Child Support (Paid)

REQUESTS

Note: After you submit your answers, you may be contacted by an office representative for further information.

If you do not cooperate in showing proof of your income and/or resources, or if your income and/or resources exceed the poverty guidelines, the assignment of your attorney will be denied or discontinued.

If you are working, please provide your last two (2) weekly paystubs or your last one (1) biweekly stubs.

If you are on unemployment, SSI, or disability, we may ask for your last payment stub or a recent letter from the Unemployment office or Disability office confirming the amount you are receiving.

There may be additional documentation requested to determine eligibility.

You may upload the requested documents with this application, or send them via fax (716) 856-0424, or e-mail info@assigned.org.

Signature *

clear

Please Upload All Court Paperwork/Income Documents Here

Additional Notes

Food Stamps (SNAP)	Medicaid
SSI	Rental/Housing Assistance
Unemployment	I do not receive any public benefits