Online Application Step 1 of 6 0% Contact InformationFirst Name*Middle Name*If you do not have a middle name, please write "NONE". Last Name*Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Cell Phone*Alternate PhoneEmail* Save and Continue Later Service InformationDate of Birth* MM DD YYYY Ethnicity*Please ChooseWhite/CaucasianBlackAsianNative AmericanHispanicMiddle EasternOtherGender*Please ChooseMaleFemaleTransgenderBranch of Service*Please ChooseAir ForceArmyCoast GuardMarine CorpsNavyDid you separate from the military within the last 24 months?*YesNoYears of Service, e.g., 1997-2004*Status* Active Service Member Disabled Reservist Veteran Post 9/11?*YesNo Save and Continue Later Monthly Household Income & Assets Wages per Month*Unemployment Insurance*VA Benefits*General Relief*Social Security Retirement (SS)*Social Security Disability Income (SSDI) / Disability Insurance Benefit (DIB)*Supplemental Security Income (SSI)*Pension/Retirement*OtherTotal Monthly IncomeAutomatically Calculated Do you have any readily available funds?Please enter a description and a total estimated value below.Description of readily available funds in a few words*Examples include stocks, bonds, recreational vehicles, and investment properties.Estimated total amount or value of readily available funds* Save and Continue Later Household InformationMarital Status*Choose OneSingleMarriedSeparatedDivorcedWidowedNumber of Adults in Household*Number of Children in Household* Save and Continue Later Assistance Information Have you been helped by Veterans Legal Institute before?*YesNoHow did you hear about us?*Google SearchFriend or FamilyStrong Families, Strong ChildrenVolunteers of America Los AngelesOrange County Veterans Service OfficeRiverside Veterans Service OfficeSan Bernardino Veterans Service OfficeVA HospitalStarbucksSaddleback CollegeCity of Mission ViejoNorth County Vet CenterOCVMFCOtherHave you been involved in a legal matter whereby the opposing party was represented by VLI?*YesNoName of opposing party(ies), put "N/A" or "None" if your issue has no opposing party:*Type of Legal Service You Are Seeking* Discharge Upgrade Expungement Estate Planning Bankruptcy Small Business Assistance Compromise of Arrears Non-Profit Assistance Guardianship/Conservatorship Veterans Benefit/Appeals Other Please explain "other"Please include a summary of your legal issue and any upcoming deadlines/dates we should be aware of* Save and Continue Later Terms and Conditions This application is simply an inquiry for eligibility for VLI’s services and does not create an attorney-client relationship. VLI does not promise to provide any additional service or represent me in any trial/hearing proceedings unless I sign a formal representation agreement. I understand that, if my case is accepted, I will be responsible for incidental costs such as administrative costs and filing fees. Further, I understand that VLI is independent of the Department of Defense and that VLI will represent my interests, not those of the Department of Defense or the United States Government. Prior to undertaking representation, VLI will prepare a letter detailing the agreement with me and explaining each party’s responsibilities. I may terminate this agreement at any time with written notification. VLI reserves the right to terminate its representation at any time. If VLI terminates its representation, it will provide written notification to the mailing and/or email address I provided above. I have given correct information on my current financial situation. I will notify VLI promptly of any changes in my address, telephone number, and/or circumstances which might affect my financial eligibility for its service. I agree to cooperate in providing information and documents. If applicable I understand that I am responsible for the timely filing of the legal document prepared by VLI unless VLI agreed to file the legal document. If I do not qualify for a fee waiver, I understand that I will be responsible for any cost associated with the timely filing of the legal document. I understand that if I meet the requirements for placement with a volunteer attorney, VLI may try to find me a volunteer attorney to give me additional help. VLI may provide her or him with information and documents regarding my case. VLI cannot guarantee that it will find a volunteer attorney. If after a reasonable amount of time and effort my case cannot be placed, my case will be closed. Except for out-of-pocket costs such as filing fees, VLI and any volunteer attorney we refer your case to will not charge you for their legal services. Please inform us if a volunteer attorney attempts to charge you for their legal services. Accept the Terms* I understand and accept the above terms and conditions. Signature*Your IP address is being recorded: 184.108.40.206 08/18/2019YOU MUST ACCEPT THE TERMS AND CONDITIONS TO SUBMIT THIS FORMPhoneThis field is for validation purposes and should be left unchanged. Save and Continue Later This iframe contains the logic required to handle Ajax powered Gravity Forms.