Application foR other resources


Please note: The DV LEAP Offices will be closed on January 18th for MLK Day and January 20th for the Presidential Inauguration. There may be a slight delay in our application review process at this time.
Our Legal Team will get back to you as soon as possible in regards to your application.

Thank you for your patience.


A. Applicant Information

Full Legal Name (First Middle Last): *

Preferred Name (First Middle Last):

HOW WOULD YOU LIKE TO BE ADDRESSed IN
CORRESPONDENCE?
(Example: Jane, Jane Doe, Mr. Doe,
Miss. Doe):

Date of Birth: *

Gender/Gender Identity:

(Please note: This question is optional but must be asked for grant
reporting purposes.)

Sexual Orientation:

(Please note: This question is optional but must be asked for grant
reporting purposes.)

Your Pronouns:*

Race/Ethnicity:*

Did Another organization refer you to Dv leap?*

(If yes, please put the name of the organization here.
If no, please write N/A.)

Email Address:*

(Please make sure your email is correct as our initial communication
regarding this application will be by email.)

Is it safe to email?*

Phone Number: (Including area code)*

Is it safe to call?*

Is it safe to leave a message?*

Current Mailing Address:*

City:*

State:*

Zipcode:*

Is It Safe to Receive Mail Here?*

Are You Registered in the "Safe AT Home" Program?

Do You Identify as Having a Disability?

If Yes, is there Anything DV LEAP Should Know
or do to Best Serve you and your needs?

in what language are you more comfortable communicating?*

Are there any other languages you use?

do you have a fee waiver in your case?*

please select the average number of people living
in your household over the past 12 months,
and indicate whether your annual gross (before taxes) income was above or below the corresponding
amount listed below.
*

For grant reporting purposes, DV LEAP asks about income.
This information is required but will NOT affect your eligibility
for our services.


B. Type of assistance


DV LEAP can only provide legal representation for those seeking to appeal a final order.  We can provide limited resources for those who are not seeking an appeal.  Please answer the following questions if you are seeking these resources.

what kind of assistance are you seeking?*

Are you also looking for "Research/Written Resources"?
If yes, please select which research or written resources you're looking for:

C. information about the case

state case is located in:*

county the case is located in:*

Case number:

type of case:*


D. Information about your legal representation

Do you have a lawyer representing you?*

Lawyer's name:

Lawyer's firm/organization:

Lawyer's email address:

lawyer's phone number:

(Including area code)


e. Information about your opposing party

opposing party's Name (First Middle Last): *

opposing party's date of birth: *

Did your opposing party have a lawyer
representing them?
*

opposing lawyer's name:

opposing lawyer's firm/organization


F. Information about DOMESTIC VIOLENCE
(Domestic violence can occur between two people who have or have had an intimate relationship or have a child in common or are
closely related. Domestic violence can be physical, emotional, sexual or financial. It can happen once or more than once.
It can happen recently or a long time ago. We understand that answering these questions may be difficult and thank you for responding.)

HAVE YOU EXPERIENCED DOMESTIC VIOLENCE?*

Did the opposing party in your case commit domestic violence against you and/or your child(ren)?*

if yes, please describe:

(Optional) - (150 words):


G. other questions

Is there any other information about your case
or your situation that you want to share with us?

(150 words):

Thank you! Your submission has been received!

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