Southern Indiana Pro Bono Referrals, Inc.

Intake Form
Regarding your Application for Legal Assistance

Thank you for applying to Southern Indiana Pro Bono Referrals, Inc. for legal assistance. Please return to us the attached forms and information quested:
-  Intake Form, you MUST fill in all the requested information and write a narrative of your situation. If you do not complete the intake form, or the narrative, the application will be denied. All information provided is confidential.
-  Proof of Income, you need to provide proof of your household income.
-  Court orders, rulings, or notifications, and child support worksheets in your case.
-  Memorandum of Understanding signed giving us permission to release your information to a volunteer attorney. A copy of your valid Driver License or State ID must accompany the release.
-  Guidelines signed acknowledging you understand the program parameters.
NOTE:
1. Notify us of any change in household income.
2. We MUST have current contact information. If we try to contact you and are not successful a reject letter will be sent to the address we have on file.
3. We are a referral program only. We do not have attorneys on staff. We are not capable of responding to emergencies. It may take us weeks to evaluate your application depending on receiving information required.
4. The volunteer attorneys take cases without pay solely on their availability. Please respect their time.
If you have any questions please call 812-288-8002.

Sincerely,

Southern Indiana Pro Bono Referrals, Inc.

Please note we are a referral program only. We have no attorneys on staff. We will refer your case only if there is a legal remedy for your problem, and we have a volunteer attorney available to take your case.

Assets:
Residence: *

Own Rent Other option
Monthly Mortgage/Rent: *
Monthly Utilities: *
Bank Account Balance: *
Savings Account Balance: *
Year/Model of Vehicle(s) and their value: *
401(k) and/or Retirement Accounts (name & balances): *

Household Members:
Number of Adults residing in your home: *
Number of Children residing in your home full-time (under 19): *
Name: *
Relationship: *
Age: *
Date of Birth: *

/ Month / Day Year
Monthly Income: *
Income Source: *
Name: *
Relationship: *
Age: *
Date of Birth: *

/ Month / Day Year
Monthly Income: *
Income Source: *
Name: *
Relationship: *
Age: *
Date of Birth: *

/ Month / Day Year
Monthly Income: *
Income Source: *
Name: *
Relationship: *
Age: *
Date of Birth: *

/ Month / Day Year
Monthly Income: *
Income Source: *
Name: *
Relationship: *
Age: *
Date of Birth: *

/ Month / Day Year
Monthly Income: *
Income Source: *
Name: *
Relationship: *
Age: *
Date of Birth: *

/ Month / Day Year
Monthly Income: *
Income Source: *
Name: *
Relationship: *
Age: *
Date of Birth: *

/ Month / Day Year
Date
Monthly Income: *
Income Source: *
First Child's Name: *
Relationship: *
Age: *
Date of Birth: *

/ Month / Day Year
Second Child's Name: *
Relationship: *
Age: *
Date of Birth: *

/ Month / Day Year
Third Child's Name: *
Relationship: *
Age: *
Date of Birth: *

/ Month / Day Year
Fourth Child's Name: *
Relationship: *
Age: *
Date of Birth: *

/ Month / Day Year
Fifth Child's Name: *
Relationship: *
Age: *
Date of Birth: *

/ Month / Day Year
Sixth Child's Name: *
Relationship: *
Age: *
Date of Birth: *

/ Month / Day Year
Seventh Child's Name: *
Relationship: *
Age: *
Date of Birth: *

/ Month / Day Year
Eighth Child's Name: *
Relationship: *
Age: *
Date of Birth: *

/ Month / Day Year
Ninth Child's Name: *
Relationship: *
Age: *
Date of Birth: *

/ Month / Day Year
Tenth Child's Name: *
Relationship: *
Age: *
Date of Birth: *

/ Month / Day Year

Opposing Party Information:
Name *
Prior Names
Birth Date, If known

/ Month / Day Year
Relationship to you: *

Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Telephone #

-
Cell #

-
Work #

-
U.S. Citizen: *

Yes No Don't Know
Name of Attorney: *

What is your problem? *
Who is involved? *
What do you want us to do for you? *

Memorandum of Understanding
I, {name}, am requesting a referral to a volunteer attorney through the Southern Indiana Pro Bono Referrals, Inc. (SI-PBR) for representation in the following matter:

{matter}

I understand that should a volunteer attorney review my case, their acceptance of my case is purely voluntary on their part. I further understand that SI-PBR is only a referral service and cannot force an attorney to accept my case. It has been made clear to me that I must verify my financial need for assistance before I will even be considered for a referral. I also understand that there are a limited number of volunteers and that I may be put on a waiting list. I also know that I must be truthful and respectful. I must cooperate with the attorney handling my case. Any disrespect or abuse of the attorney/client relationship by me will be cause for my volunteer attorney to withdraw from my case at their discretion.

I also may withdraw my request for assistance at any time. It is understood that I have the responsibility to inform SI-PBR of any change in my income, my household members, or my other resources. I understand that should I become ineligible for services for any reason SI-PBR may withdraw the referral or the volunteer attorney may withdraw from my case.

I hereby authorize Southern Indiana Pro Bono Referrals, Inc. to release records and information pertaining to my case to the volunteer attorney(s).
Client Signature *

Clear
Today's Date *

/ Month / Day Year
Declaration of Citizenship
I hereby declare that I am a citizen or permanent legal resident of the United States.
Client Signature *

Clear
Today's Date *

/ Month / Day Year

SI-PBR Guidelines
APPLICATION

You need to fill out forms to determine your qualification for services. This paperwork must be filled out accurately and completely.

Factors used in determining your qualification include: income, the type of legal issue, the merits of your case, and whether we have available volunteers.

If you qualify, we will notify you that your case has been approved to begin the search for a volunteer attorney to handle your case at no charge. We cannot guarantee that a volunteer with the necessary expertise and time will be found. If we are not able to place your case timely for your needs, you may want to proceed by other means. If you hire an attorney, please advise us as soon as possible so that we may close your file.

RELEASE OF INFORMATION

To place your case with a volunteer attorney, we need to be able to release limited information initially to avoid conflicts. Once a case has been accepted by a volunteer, the remaining information you have provided will be forward to that attorney. By applying for our services and seeking a pro bono attorney, you are agreeing that we may release such information to a pro bono attorney and potential pro bono attorneys as necessary.

SERVICES TO OPPOSING PARTY

It is possible that the other individual(s) in your case may seek assistance from us. Please be aware that we may take an application from an opposing party in your case. Be assured that all information collected from you will be kept separate and confidential. In the event that we place volunteers with both sides of a case, the volunteer attorney for the opposing party will not have access to any of your information through our services.

ATTORNEY FEES

If a volunteer accepts your case, the attorney will represent you without charge unless awarded attorney’s fees by the court to be paid by the opposing party. If a court awards attorney fees to be paid by the opposing party to your volunteer attorney, your attorney is allowed to accept such fees as ordered.

COPIES OF DOCUMENTS

Any documents you provide to our office will not be returned to you. Accordingly, please do not leave any original documents with us. We may be able to make copies for you but we have a very limited budget so it is not a guarantee. Please note, copies provided to us will remain part of your file in this office, regardless of our ability provide you with services.

CLIENT RESPONSIBILITIES

Filing Fees and Costs: The court will normally, but not always, waive the filing fees for individuals who qualify for our services. The notable exception is the bankruptcy petition filing fee which is rarely waived. In the event the fees in your case cannot be waived, you will need to be prepared to pay the appropriate filing fee if necessary.

While volunteer attorneys with our program agree to handle cases without charging the clients fees for their work, they are not necessarily agreeing to spend their own money to cover additional costs and expenses in your case. Such costs may include postage, copying charges, service by the Sheriff or certified mail, depositions, Guardian ad Litem fees, or mediation fees. Accordingly, if you are assigned a volunteer, it is very important that you talk with your attorney in your first meeting to reach an agreement about potential costs that may arise in your case.

COOPERATION WITH YOUR VOLUNTEER ATTORNEY

If you are placed with an attorney, you must cooperate with in prosecution and/or defense of your case. You must keep all scheduled

appointments and be prompt, courteous and prepared. Do not bring your children to meetings with your attorney.

Do not report anything about your case to any “social media” sites you may belong to, or send any information about your case through texting or e-mail, etc. (except to your attorney from a private email address). Opposing parties, their attorneys, and representatives routinely monitor such sites and seek e-mail and text addresses of claimants to obtain information, and can subpoena such information directly from the service providers. Not only could you damage your case, but any “friend” on your site could be forced to become a witness and discuss all conversations they ever had with you. Please take this warning seriously.

When your case is completed, your attorney will withdraw from further representation and will is not required to appeal a court decision on a pro bono basis.

An attorney assigned to you is strictly a volunteer and is not obligated by any rule of law to represent you without charge. The attorney has agreed to provide you with a consultation but there is no guarantee that he or she will negotiate or litigate your matter to conclusion; that decision is left to the attorney’s professional judgment. The attorney is not employed by or otherwise associated with Southern Indiana Pro Bono Referrals or any of the Self-Service Legal Centers, other than volunteering to assist you with your specific legal problem for a limited time without charge.

PLEASE NOTE: WE WILL CLOSE YOUR CASE IMMEDIATELY, if:
1. You misrepresent information in your application;
2. You fail to show for scheduled appointments; or
3. You don’t cooperate with your attorney.
Failure to cooperate is grounds for your attorney to withdraw from your case and you will no longer be eligible for further assistance.

REPORTING NEW INFORMATION

Notify our office immediately if you change addresses or contact information prior to placement with an attorney. If we cannot locate you, we will have to close your case.

Once approved and until you are placed with a volunteer attorney, you must keep our office notified of any significant developments in your case (i.e. if you are served with a court paperwork or a court date is set in your case).

Until you are placed with an attorney, you must inform us of any household income changes to keep your application updated. We reserve the right to inquire further into your financial situation.

I hereby acknowledge that I have read and understand the above policies and have received a copy of the same.
Client Signature *

Clear
Today's Date *

/ Month / Day Year
Should be Empty:

Southern Indiana Pro Bono Referrals, Inc.

Intake Form

Income:

Assets:

Household Members:

List of Children that are the subject of this case:

Opposing Party Information:

Case Information:

Type of Matter:

Memorandum of Understanding

Declaration of Citizenship

SI-PBR Guidelines

Useful Links

Contact Us