Modest Means Participant Application

Name(Required)

First Last

Email(Required)

Phone(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Gathering Info about Your Legal Issue

Areas of Legal Help Check the box or boxes related to your legal needs. We are unable to help in other practice areas. We cannot refer lawyers for personal injury, disability, business contracts, constitutional law, attorney malpractice, federal claims, immigration, or intellectual property. If you do not know which area you need, you may call 801-297-7049 for assistance.

Which area of legal help do you need?(Required)

Provide a brief description of your legal matter.(Required)

County(Required)

List the county where the lawyer should practice

Name(s) of opposing party:(Required)

Name of opposing attorney (if known)

Name/location or court (if known)

Language - does the attorney need to speak a language other than English?

Spanish

Vietnamese

Arabic

Other

List names of any lawyer you already contacted (or who you would NOT want us to refer)

Which Judicial District?

1st (Box Elder, Cache, and Rich Counties) 2nd (Davis, Morgan, and Weber Counties) 3rd (Salt Lake, Summit, and Tooele Counties) 4th (Juab, Millard, Utah, and Wasatch Counties) 5th (Beaver, Iron, and Washington counties) 6th (Garfield, Kane, Piute, Sanpete, Sevier, and Wayne Counties) 7th (Carbon, Emery, Grand, and San Juan Counties) 8th (Daggett, Duchesne, and Uintah Counties)

Eligibility Questions

Financial Information Please enter this information for our records. This helps us when talking with lawyers about the program and recruiting them to offer reduced rate services.

Number of Persons in Household:(Required)

List Income from all household members

Please use whole numbers without any commas, such as 3500. Persons. This includes a spouse/legal partner and dependents (not roommates who live independently and not a significant other). A dependent is a person living in your household who receives more than 50% support for their livelihood from you. Income. This includes income from adults or children where the money is used on household expenses (not including, for example, money from a child who makes $50 a week babysitting to save for college

Wages (monthly total gross income, not take home pay)(Required)

Social Security (monthly)(Required)

Child Support or Spousal Support that you receive (monthly)(Required)

This means any court-ordered money that you receive from the other parent or ex-spouse.

Child Support or Spousal Support that you pay (monthly)(Required)

This means any court-ordered money that you pay to the other parent or ex-spouse.

Money in bank account(s) (current balance of checking and savings)(Required)

Other Source or Amount of Income

Important Info about Qualifying

Please be aware your lawyer may ask you additional questions during their office's intake process to confirm your eligibility for the program. The Modest Means lawyer has the final say in the qualification process for whether or not you qualify for reduced rates.

Non-Refundable Administrative Fee(Required)

Price:

A $25 non-refundable administrative fee.

Credit Card

American Express

Discover

MasterCard

Visa

Card Number

Expiration Date

Security Code ** Name as it shows on the credit card. **

Modest Means Participant Application

You will be referred to a lawyer who charges a reduced hourly or flat rate. These lawyers may require payment up front (a retainer) for their services. The application gives us needed information about you and your situation. Qualifying applicants will receive an email, which certifies that they qualify for the Modest Means program to use with participating lawyers.