Kansas Legal Services

Online Application

Versión en Español

Applicant Information

* Required field

Applicant First Name:

*

Applicant Middle Name:

Applicant Last Name:

*

Applicant Other Name in last 5 years:

SSN:

Safe/Secure Street Address:

If you have a safe/secure street address at this time.

City:

State:

Zip:

County of Residence:

County of Court:

Case Type:

Date of Birth:

Gender:

Race:

Marital Status:

Number of children in home:

Number of adults in home:

Have you, or has anyone *in your home*, ever been in the U.S. Military including the National Guard or Reserve?:

* Resident Status: Permanent Resident -OR- Permanent Resident pending approval married to a U.S. Citizen -OR- Permanent Resident pending approval who is a parent of an unmarried child under the age of 21 whose other parent is a US Citizen.

U.S. Citizenship:

Primary Language:

* Include area code. Enter “none” if you do not have a phone number

Safe/Secure Phone #:

Safe/Secure Alternate Phone #:

Best Time To Call:

Safe/Secure Email Address:

* Enter “none” if you do not have an email address

Adverse Information

An Adverse is the opposing party in your case.

It is extremely important that any law firm have as much information as possible about the person(s) on the opposite side of each case before answering even one question.  Even though we are a nonprofit organization, we are still a law firm and have the same ethical responsibility as any private law firm.

You do not have to enter this information, if you don’t know it.

Adverse First Name:

Adverse Middle Name:

Adverse Last Name:

Adverse Other Name in last 5 years:

Income Information

Frequency:

Applicant (you)

Others in your home

Employment:

Self Employment:

State Assistance:

Child Support:

Unemployment:

SSI/SS:

Pension:

Alimony:

Other Income:

Asset Information

Use

Value

Vehicle 1:

Vehicle 2:

Vehicle 3:

Includes cash in banks, stocks, investments, IRAs or non-employment related retirement accounts

Total Cash On Hand:

Total value (equity) of any/all real estate you might own *other than* where you currently live at this time.

Real Estate *other than* where you live:

If you put all household assets other than vehicles to the curb and sold all for bottom dollar — household furnishings, clothing, dishes, artwork, etc. — what is the total you MIGHT get for all combined?

Total Value Other Items:

Expense Information

Back Taxes:

Regular monthly payments on back taxes

Rent or Mortgage:

Monthly

Child Support:

Monthly payments

Child Care:

Monthly cost

Medical:

Monthly health insurance premiums, monthly prescription costs or regular payments on past due medical bills