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2. Madison County ACP Application for Assignment of Counsel

   *Eligibility is determined by answers and financial income guidelines. Please answer all questions the best you can*  

4. Client Information
6. Name*
7. Email Address*
9. Date of Birth*
   Date of Birth
10. Age*
11. Sex
    -- Select One --MaleFemale
12. Phone*
14. Physical Address*
16. City*
17. State*
18. Zip Code*
20. Mailing Address

    (if different from physical address)

22. City
23. State
24. Zip Code
26. Do you speak English?*

    1. Yes

    1. No
27. Marital Status
29. What City/State and Country were you born in?*
31. Number of dependents in household*

    (include minors under the age of 26, adults who are caregivers, elderly or disabled)

33. Client Financial Information
35. Do you receive any of the following: (Please checkmark any/all that apply)*

    1. Public Assistance
    2. SSI/SSDI

    1. Food Stamps

    1. Medicaid

    1. None
37. Occupation*
38. Name of Employer
40. Address of Employer
42. Amount of NET Pay (take home pay)*
43. Paid*

    1. Weekly
    2. Bi-Weekly

    1. Monthly
    2. Yearly
45. Current Balance for Checking Account(s)*
46. Current Balance for Savings Account(s)*
48. 401K/Stocks/Bonds (Value)*
49. Unemployment Benefits*
50. Pension*
52. VA Benefits*
53. Workers Comp*
54. Do You Own Your Home?*
    -- Select One --YesNo
56. Current Market Value of Home*
57. Amount Owed on Home*
59. Number of Vehicles Owned*
60. Market Value of Vehicle(s)*
61. Amount Owed on Vehicle(s)*
63. Monthly Expenses
65. Food*
66. Rent/Mortgage*
67. Car Payment*
69. Utilities*

    (Heat/Internet/Electric, Etc.)

70. Child Care/Support*
71. Medical Bills*
73. Credit Card/Installment Debts*
74. Tuition/Education *
75. Alimony*
77. Charges*

    Please list all charges

79. Electronic Signature Agreement*

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
81. Electronic Signature*
Leave This Blank:


83. 1. Receive an email copy of this form.
84. Email address

    This field is not part of the form submission.

85. Submit Submit and Print

* indicates a required field