Online Application

Applicant First Name:

Kansas Legal Services

Online Application

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	Applicant Information
			* Required field

	Applicant Middle Name:

	Applicant Other Name in last 5 years:

	SSN (last 4 digits):

	City:

	State:

	Zip:

	County of Residence:

	County of Court:

	Case Type:

	Date of Birth:

	Gender:

	Pronouns:

	Race:

	Ethnicity:

	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:

	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

	Expense Information