What is your name?
Enter up to 3 other names you have used:
How can we reach you?
- Count yourself
- Count everyone in your household that you are responsibile for and anyone that is responsible for you even if you are not related.
- Count your partner if you are married or if you have a child together, unless that person is harming you.
- Count your minor children (under 19 years of age) if they have never lived on their own, or if they have moved back into your home with an intent to stay permanently.
- Do not count an adult child who has lived independently, but moved back to the home with the intent of it being a temporary living arrangement.
- Do not count an adult living in the household because of a disability or need for regular care.
- Do not count the abuser in your household if you are a victim of domestic violence.
- Do not count roommates.
We need information about your household income. For household income, you need to provide the gross income amount, which is the amount before taxes are taken out, for every person you count in your household.
Household Employment Income
Other Household Income
Household Asset Information
We need information about the property you own. Provide the total amount of each asset category for EVERY person you counted in your household.
What is the garage sale value of your personal posessions?
List only those expenses paid by the people you included in your household.
Note: A criminal charge in the last 2 years MAY exclude you from being able to get a case set aside.