Client Information Name * First Name Last Name Date of Birth * MM DD YYYY Email * Address Address 1 Address 2 City State/Province Zip/Postal Code Country Phone (###) ### #### Have you ever been a client with Indian Legal? Yes No If 'No', who referred you to us? Household and Income Marital Status Single Married Separated Divorced Household Size * You, plus any dependents Race/Ethnicity * Caucasian African American American Indian Hispanic Asian/Pacific Islander Multi-Racial Are you enrolled in a Federally Recognized Tribe? Yes No If 'Yes', which tribe are you enrolled with? Income Source(s) Employment Public Assistance SSI Tribal Per Capita Other Monthly Income Amount * Please list your monthly income from all sources. Case Information What type of case do you need help with? * Civil Criminal Legal Advice Only Description of case * What are you being charged with? Or what type of civil matter is it? Court Information What County is your court case in? * St. Louis County (Duluth) St. Louis County (Hibbing) St. Louis County (Virginia) Aitkin County Carlton County Cook County Lake County Bois Forte Tribal Court Other If 'Other', where is your court case located? Please note that any other court locations are out of our service area, but we may be able to provide referrals in some circumstances. Additional Comments Is there anything else you would like us to know about the case? Upcoming court date, name of other party, etc. Thank you for submitting your intake form. Please allow 3-5 business days for us to review your intake and provide you with a response. Please note that submission of intake does not guarantee that Indian Legal Assistance Program will represent you or provide legal advice. If we are unable to assist for any reason, we will provide you with contact information for other area agencies who may be able to help instead. Miigwech!