MCC Legal Assistance Intake Form

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Eligibility requirements:
187.5% of the federal poverty guidelines
Children living in your home between the ages of 0-17 years

Ethnicity

Caucasion

African America

Native American

Hispanic

Asian/Pacific Islander

Marital Status

Single

Married

Separated

Divorced

Are you a citizen of and eligible alien of the USA?

Yes

No

Gender

Male

Female

Date of Birth:

Hidden

Name:(Required)

First Last

Phone(Required)

Email(Required)

Hidden

Address(Required)

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

Hidden

Name of Adverse Party:

# of People Living in the Household:

Total Household Income:(Required)

Source of Income:(Required)

Other:

List the VYJ program you are currently involved in:

Do you have children between the ages of 0-17 currently living in your home?(Required)

Yes

No

Hidden

Brief Description of Legal Problem:(Required)

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Make A Difference Today

Contact

900 Jordan, Suite 102
Shreveport, LA 71101

Hours: M-F 8:30am-4:30pm

318-425-4413
info@vyjla.org

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