- Legal Aid of Nebraska

Set Aside and Record Sealing Clinic Application

Step 1 of 3

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Legal Aid of Nebraska will use the information you provide to see if you qualify for services. However, completing the application does NOT mean Legal Aid of Nebraska will accept your case or that you are a client of Legal AId of Nebraska. Legal Aid of Nebraska cannot represent everyone who applies for help.

If you are using a computer that does not belong to you, remember to close out of the browser completely to protect your private information.

You must have an email address and phone number to use this online application. If you do not, contact one of our hotlines. https://www.legalaidofnebraska.org/how-we-help/call-for-help/ If you do not hear back from us, it is yoiur responsibility to contact us.

Citizenship Status

I am a ...(Required)

US Citizen

Non-Citizen

Are you legally residing in the United States?(Required)

Yes

What is your immigration status?(Required)

What is your Visa number?

When does your Visa expire?

Month

Day

Year

What is your green card number?

Unfortunately, if you are not a citizen or legal permanent resident, we cannot help you. You may be able to find an attorney through the Nebraska Find-a-Lawyer service, or have a question answered through the ABA Nebraska Free Legal Answers service. The addresses for the websites for these services are:

https://www.nefindalawyer.com/
https://ne.freelegalanswers.org//

How did you hear about this clinic?(Required)

What is your name?

First Name(Required)

Middle Initial

Last Name(Required)

Suffix (e.g. Jr., Sr., III)

Have you gone by any other names, such as a given-name or former name?(Required)

Yes

Enter up to 3 other names you have used:

Other Name(Required)

Other Name

Address

Provide the address where you live. If you are homeless, provide an address where you spend most of your time.(Required)

Street Address Address Line 2 City State ZIP Code

Is this a safe address to receive mail?(Required)

Yes

Do you have an alternate address where it is safe for you to receive mail?(Required)

Yes

Safe Mailing Address(Required)

Street Address Address Line 2 City State ZIP Code

How can we reach you?

Email(Required)

Phone(Required)

May we text you on this phone?(Required)

Yes

Do you have another safe phone number?(Required)

Yes

Second Safe Phone Number(Required)

May we text you on this phone?(Required)

Yes

Personal Information

Social Security Number(Required)

Date of Birth(Required)

Month

Day

Year

Gender(Required)

Which pronouns do you use?(Required)

Race/Ethnicity(Required)

Are you enrolled in a Native American tribe?(Required)

Yes

Please select the Native American tribe you are enrolled in(Required)

Are you eligible for enrollment in a Native American tribe?(Required)

Yes

Please select the Native American tribe you are eligible for enrollment in(Required)

(First, MI, Last) Gender DOB Enrolled or eligible for enrollment in Native American Tribe?(Required)

Do you need an interpreter?(Required)

Yes

What language?(Required)

Have you ever served in the military, including the Reserves, National Guard, Army, Navy, Air Force, Marines, or Coast Guard?(Required)

Yes

Has anyone in your household ever served in the military?(Required)

Yes

Are you disabled?(Required)

Yes

Is your disability due to a cognitive impairment? (problems with memory, or understanding)(Required)

Yes

Do you have a physical disability?(Required)

Yes

What is your marital status?(Required)

Household Size

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.

Adults (age 19 or above)(Required)

Please enter a number greater than or equal to 0.

Children (enter 0 if none)(Required)

Please enter a number greater than or equal to 0.

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.

Personal Property (enter 0 if none)(Required)

Please enter a number greater than or equal to 0.

What is the garage sale value of your personal posessions?

Real Estate

If you own any real estate, not including the home you live in, list the value of that property.

Vehicles

What is the value of any vehicles you do not use for transportation to work or school, such as RVs, classic cars, or boats?

Retirement Accounts

How much money do you have in IRA/401k/403b or other retirement accounts?

Cash & Other Accounts

How much money do you have in savings accounts, checking accounts, money market accounts, stocks, bonds, investments, and cash on hand?

Household Income

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

Do you or anyone in your household have income from employment ?(Required)

Yes

Hours per week(Required)

Please enter a number greater than or equal to 0.

Wages per hour(Required)

Please enter a number greater than or equal to 0.

Do you or anyone in your household have other employment?(Required)

Yes

Hours per week(Required)

Please enter a number greater than or equal to 0.

Wages per hour(Required)

Please enter a number greater than or equal to 0.

Do you or anyone in your household have other employment?(Required)

Yes

Hours per week(Required)

Please enter a number greater than or equal to 0.

Wages per hour(Required)

Please enter a number greater than or equal to 0.

Other Household Income

Do you or any members of your household have income from other sources?(Required)

Yes

Examples of income from other sources include benefits like SSI, SSDI, Social Security Retirement and income you receive from any source other than from working, such as child support or alimony.

Type of income(Required)

How often is this income received?(Required)

every week

every two weeks

once per month

annually

How much is received?(Required)

Please enter a number greater than or equal to 0.

Do you or a member of your household have income from additional sources?(Required)

Yes

Type of income(Required)

How often is this income received?(Required)

every week

every two weeks

once per month

annually

How much is received?(Required)

Please enter a number greater than or equal to 0.

Do you or a member of your household have income from additional sources?(Required)

Yes

Type of income(Required)

How often is this income received?(Required)

every week

every two weeks

once per month

annually

How much is received?(Required)

Please enter a number greater than or equal to 0.

Do you expect your income to change within the next 90 days?(Required)

Yes

Household Expenses

List only those expenses paid by the people you included in your household.

Do you or any members of your household have any expenses?(Required)

Yes

Examples of expenses include rent, a car payment, daycare, etc.

Type of Expense(Required)

Amount?(Required)

Please enter a number greater than or equal to 0.

How often do you pay this expense?(Required)

Do you have other expenses?(Required)

Type of Expense(Required)

Amount?(Required)

Please enter a number greater than or equal to 0.

How often do you pay this expense?(Required)

Housing

What is your housing situation?(Required)

Rent

Own

Homeless

Other

Are you at risk of losing your housing?(Required)

Yes

Is your housing at risk because of your mortgage?(Required)

Yes

Which of the following best describes your rental situation?

I have a private landlord and receive no ongoing rental assistance

I live in a public housing facility owned by a local Housing Authority

a housing voucher, Section 8, or live in a rent subsidized building

I receive other rental assistance, such as General Assistance.

Which of the following best describes your home?

Single Family Home

Mobile Home that I own

Condo, Townhome, duplex, triplex

Which of the following best describes your homelessness.

I am living in a shelter facility for people experiencing homelessness or domestic violence.

I am homeless, but have found other living arrangements, such as living with friends, or in my car?

Which of the following best describes your housing situation?

I am incarcerated in jail or prison

I am living in a nursing home, assisted living facility, or other long-term care facility

I am in a hospital

Other

Abuse

Are you a victim of abuse (physical, emotional, mental, human trafficking, etc .)?(Required)

Yes

Are you a victim of sexual assault?(Required)

Yes

Are you a victim of domestic abuse?(Required)

Yes

Are you a victim of stalking(Required)

Yes

Are you a victim of human trafficking?(Required)

Yes

What is your relationship with the person who abused you ?(Required)

Surveys

We sometimes send satisfaction surveys by email or text. Is it ok if we send you a survey?(Required)

I would prefer an emailed survey link

I would prefer a text message with a survey link

I would prefer not to be surveyed by either text or email

If you do not wish to receive a survey, please indicate why not(Required)

I don't have access to technology

I prefer surveys on paper

other

Case Information

Have you had any criminal charges or convictions in the last two years?(Required)

Yes

Criminal charges includes (but is not limited to) traffic offenses, such as speeding tickets, driving under suspension, etc.

Note: A criminal charge in the last 2 years MAY exclude you from being able to get a case set aside.

What cases do you want to set aside or seal?(Required)

In what year(s) did these charges or convictions happen? If you do not know the exact year, please estimate the year(s) approximately and list below.(Required)

Important: You will receive a call from Legal Aid to confirm your registration. You are not fully registered until you have made an appointment with Legal Aid staff.

Set Aside and Record Sealing Clinic Application

Step 1 of 3

33%

Section Break

If you are using a computer that does not belong to you, remember to close out of the browser completely to protect your private information.

Citizenship Status

I am a ...(Required)

US Citizen

Non-Citizen

Are you legally residing in the United States?(Required)

Yes

What is your immigration status?(Required)

What is your Visa number?

When does your Visa expire?

Month

Day

Year

What is your green card number?

https://www.nefindalawyer.com/
https://ne.freelegalanswers.org//

How did you hear about this clinic?(Required)

What is your name?

First Name(Required)

Middle Initial

Last Name(Required)

Suffix (e.g. Jr., Sr., III)

Have you gone by any other names, such as a given-name or former name?(Required)

Yes

Enter up to 3 other names you have used:

Other Name(Required)

Other Name

Address

Provide the address where you live. If you are homeless, provide an address where you spend most of your time.(Required)

Street Address Address Line 2 City State ZIP Code

Is this a safe address to receive mail?(Required)

Yes

Do you have an alternate address where it is safe for you to receive mail?(Required)

Yes

Safe Mailing Address(Required)

Street Address Address Line 2 City State ZIP Code

How can we reach you?

Email(Required)

Phone(Required)

May we text you on this phone?(Required)

Yes

Do you have another safe phone number?(Required)

Yes

Second Safe Phone Number(Required)

May we text you on this phone?(Required)

Yes

Personal Information

Social Security Number(Required)

Date of Birth(Required)

Month

Day

Year

Gender(Required)

Which pronouns do you use?(Required)

Race/Ethnicity(Required)

Are you enrolled in a Native American tribe?(Required)

Yes

Please select the Native American tribe you are enrolled in(Required)

Are you eligible for enrollment in a Native American tribe?(Required)

Yes

Please select the Native American tribe you are eligible for enrollment in(Required)

(First, MI, Last) Gender DOB Enrolled or eligible for enrollment in Native American Tribe?(Required)

Do you need an interpreter?(Required)

Yes

What language?(Required)

Have you ever served in the military, including the Reserves, National Guard, Army, Navy, Air Force, Marines, or Coast Guard?(Required)

Yes

Has anyone in your household ever served in the military?(Required)

Yes

Are you disabled?(Required)

Yes

Is your disability due to a cognitive impairment? (problems with memory, or understanding)(Required)

Yes

Do you have a physical disability?(Required)

Yes

What is your marital status?(Required)

Household Size

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.

Adults (age 19 or above)(Required)

Please enter a number greater than or equal to 0.

Children (enter 0 if none)(Required)

Please enter a number greater than or equal to 0.

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.

Personal Property (enter 0 if none)(Required)

Please enter a number greater than or equal to 0.

What is the garage sale value of your personal posessions?

Real Estate

If you own any real estate, not including the home you live in, list the value of that property.

Vehicles

What is the value of any vehicles you do not use for transportation to work or school, such as RVs, classic cars, or boats?

Retirement Accounts

How much money do you have in IRA/401k/403b or other retirement accounts?

Cash & Other Accounts

How much money do you have in savings accounts, checking accounts, money market accounts, stocks, bonds, investments, and cash on hand?

Household Income

Household Employment Income

Do you or anyone in your household have income from employment ?(Required)

Yes

Hours per week(Required)

Please enter a number greater than or equal to 0.

Wages per hour(Required)

Please enter a number greater than or equal to 0.

Do you or anyone in your household have other employment?(Required)

Yes

Hours per week(Required)

Please enter a number greater than or equal to 0.

Wages per hour(Required)

Please enter a number greater than or equal to 0.

Do you or anyone in your household have other employment?(Required)

Yes

Hours per week(Required)

Please enter a number greater than or equal to 0.

Wages per hour(Required)

Please enter a number greater than or equal to 0.

Other Household Income

Do you or any members of your household have income from other sources?(Required)

Yes

Examples of income from other sources include benefits like SSI, SSDI, Social Security Retirement and income you receive from any source other than from working, such as child support or alimony.

Type of income(Required)

How often is this income received?(Required)

every week

every two weeks

once per month

annually

How much is received?(Required)

Please enter a number greater than or equal to 0.

Do you or a member of your household have income from additional sources?(Required)

Yes

Type of income(Required)

How often is this income received?(Required)

every week

every two weeks

once per month

annually

How much is received?(Required)

Please enter a number greater than or equal to 0.

Do you or a member of your household have income from additional sources?(Required)

Yes

Type of income(Required)

How often is this income received?(Required)

every week

every two weeks

once per month

annually

How much is received?(Required)

Please enter a number greater than or equal to 0.

Do you expect your income to change within the next 90 days?(Required)

Yes

Household Expenses

List only those expenses paid by the people you included in your household.

Do you or any members of your household have any expenses?(Required)

Yes

Examples of expenses include rent, a car payment, daycare, etc.

Type of Expense(Required)

Amount?(Required)

Please enter a number greater than or equal to 0.

How often do you pay this expense?(Required)

Do you have other expenses?(Required)

Type of Expense(Required)

Amount?(Required)

Please enter a number greater than or equal to 0.

How often do you pay this expense?(Required)

Housing

What is your housing situation?(Required)

Rent

Own

Homeless

Other

Are you at risk of losing your housing?(Required)

Yes

Is your housing at risk because of your mortgage?(Required)

Yes

Which of the following best describes your rental situation?

I have a private landlord and receive no ongoing rental assistance

I live in a public housing facility owned by a local Housing Authority

a housing voucher, Section 8, or live in a rent subsidized building

I receive other rental assistance, such as General Assistance.

Which of the following best describes your home?

Single Family Home

Mobile Home that I own

Condo, Townhome, duplex, triplex

Which of the following best describes your homelessness.

I am living in a shelter facility for people experiencing homelessness or domestic violence.

I am homeless, but have found other living arrangements, such as living with friends, or in my car?

Which of the following best describes your housing situation?

I am incarcerated in jail or prison

I am living in a nursing home, assisted living facility, or other long-term care facility

I am in a hospital

Other

Abuse

Are you a victim of abuse (physical, emotional, mental, human trafficking, etc .)?(Required)

Yes

Are you a victim of sexual assault?(Required)

Yes

Are you a victim of domestic abuse?(Required)

Yes

Are you a victim of stalking(Required)

Yes

Are you a victim of human trafficking?(Required)

Yes

What is your relationship with the person who abused you ?(Required)

Surveys

We sometimes send satisfaction surveys by email or text. Is it ok if we send you a survey?(Required)

I would prefer an emailed survey link

I would prefer a text message with a survey link

I would prefer not to be surveyed by either text or email

If you do not wish to receive a survey, please indicate why not(Required)

I don't have access to technology

I prefer surveys on paper

other

Case Information

Have you had any criminal charges or convictions in the last two years?(Required)

Yes

Criminal charges includes (but is not limited to) traffic offenses, such as speeding tickets, driving under suspension, etc.

Note: A criminal charge in the last 2 years MAY exclude you from being able to get a case set aside.

What cases do you want to set aside or seal?(Required)

In what year(s) did these charges or convictions happen? If you do not know the exact year, please estimate the year(s) approximately and list below.(Required)

Important: You will receive a call from Legal Aid to confirm your registration. You are not fully registered until you have made an appointment with Legal Aid staff.

Set Aside and Record Sealing Clinic Application

Section Break

Citizenship Status

Address

How can we reach you?

Personal Information

Household Size

Household Asset Information

Household Income

Household Employment Income

Other Household Income

Household Expenses

Housing

Abuse

Surveys

Case Information

Set Aside and Record Sealing Clinic Application

Section Break

Citizenship Status

Address

How can we reach you?

Personal Information

Household Size

Household Asset Information

Household Income

Household Employment Income

Other Household Income

Household Expenses

Housing

Abuse

Surveys

Case Information

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