Clínica de Asistencia Legal/ LEGAL AID CLINIC
Personal Information
First Name/
Nombre
Last Name/
Apellido
Email Address/
Correo electronico
Phone Number/
Numero de telefono
Date of Birt
h/
Fecha de Nacimiento
MM/DD/YYYY
Language/ Lenguaje
Please select...
English/ Ingles
Spanish/ Español
Demographics
/Datos demográficos
Race or Ethnicity/
Raza o Origen étnico
Please select...
Hispanic or Latino
Asian
Black or African American
Middle Eastern or North African (MENA)
Native Hawaiian or Pacific Islander
American Indian or Alaska Native
White
Gender
/
Género
Please select...
Woman/Mujer
Man/Hombre
Not listed/no aparece en la lista
Prefer not to answer/Prefiero no responder
Annual Household Income
/
Ingresos anuales del hogar
Please select...
Under $26,700/Menos de $26,700
$26,701-$44,500
$44,501-$71,200
Over $71,200/Más de $71,200
Address/
Direccion
Street/
Calle
City/
Ciudad
State/
Estado
Please select...
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District Of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Puerto Rico
Virgin Island
Northern Mariana Islands
Guam
American Samoa
Palau
Zip Code/
Codigo Postal
Que tipo de servicio legal necesita?/ What kind of legal aid do you need?
Seleccione las que considere/ Select what you need
Forma de poder para proteccion de niños/ Child's power of attorney
Forma de poder para protecion de vivienda/ House' power of attorney
Consulta de leyes de inmigracion/Consult with immigration lawyer
Forma de Autorizacion de terceros de ICE/ ICE third party release
Poder notarial duradero/ Statutory durable power of attorney
Notario Publico/ Public Notary
Consulta leyes laborales/ Employment law
Algo mas/ Other
Contact Information