Application for Assistance (Group)

Name:*


Contact Person for this Application:


Title:


Address:*


City:*


State:*


Zip:*


Home Phone:*


Business Phone:


E-mail Address:*




MARITAL & FAMILY STATUS

(Each group member must provide the following information.)

SingleMarried

Employer:*


Gross Salary:*


Take Home per Week:*


Spouse's Name:


Spouse's Employer:


Gross Salary:


Take Home per Week:


Special Financial Circumstances:


*Each individual must submit a copy of his/her latest-filed individual, joint and/or business income tax return.

OTHER INCOME

Social Security:
$

Workman’s Compensation:
$

Veterans Benefits:
$

Rental Property:
$

Unemployment Compensation:
$

Pension:
$

In-Kind:
$

Support, Alimony or Maintenance:
$

Other (Please specify):


Do you own real estate?
YesNo

Real Estate Value:
$

Automobile Make:


Year:


Other Assets:


Savings:
$

Bank Name:


Checking:
$

Bank Name:
$

Other (Please specify):




Please answer the following questions:

1. Describe the nature of your art work and/or artistic activities.

2. Please explain in detail the nature of the problem for which you need legal assistance.

3. Have you consulted a lawyer concerning the above problem? If so, please provide the name and telephone number of that lawyer.

4. Are you currently represented by another lawyer? If so, please provide the name and telephone number of that lawyer.

5. How did you learn about MdVLA?

MdVLA’s funding sources may ask for names of some of our clients. If it is determined that
you are eligible for assistance, may we list your name? (Determination of your eligibility is in
no way affected by your response to this question.)
YesNo

I hereby affirm that the information contained in this application is correct and to
the best of my knowledge, complete. I request that MdVLA refer me to a panel attorney. I
agree to report immediately to MdVLA any changes in my circumstances that may affect my
eligibility.

I understand that MdVLA makes no representation as to the skill of the referred lawyer
nor as to a degree of successful representation.

I understand I will be represented by the referred lawyer or the referred lawyer’s law
firm and not MdVLA. MdVLA is only a legal referral organization.

You will be asked for a non-refundable administrative fee of $100 for a group in the form of check or money order payable to Maryland Volunteer Lawyers for the Arts.

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