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TELL US ABOUT YOU

First Name *

Last Name *

Birth Date

// (mm/dd/yyyy)

Address 1 *

Address 2

City *

State/Province *

Zip *

Email *

Phone *

Race *

Gender *

Transgender *

Sexual Orientation *

Veteran Status *

Active Military Status *

Disability *

Please estimate your gross monthly income. *

How many people live in your household? *

How did you hear about us? *

If other, please describe:

TELL US ABOUT YOUR LEGAL SITUATION

Do you have a legal deadline? For example, a scheduled foreclosure sale or ongoing garnishment. *

Yes
No
Don't Know

If you answered yes, when is the deadline?

What is the legal issue that you are seeking assistance for? Please check all that apply. *

Debt Collection
Medical Debt
Credit Reporting
Foreclosure Prevention
Mortgage Servicing
Student Loan
Automobile Fraud
Bankruptcy
Other Consumer Legal Issue

Please briefly describe your situation:

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