New Volunteer OrientationNon-Attorney VolunteersVolunteer BenefitsVolunteer ResourcesCase DurationsFellowshipsLaw StudentsAvailable Cases CVLS INTAKE FORM Step 1 of 714%Intake PersonnelParalegalAttorney*Clinic Name*Date MM slash DD slash YYYY Would you like to receive a copy of this form upon submission? No YesIntake Email Which email address should we send the copy to?Client InformationName*Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Primary Phone*Secondary PhoneEmail Last 4 of Client's Social Security NumberAdverse PartyNameAddress Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Last 4 of Adverse Party's Social Security NumberAttorney NameAttorney PhoneHouseholdHousehold - is composed of the following persons sharing a common residential unit (house, apartment, room, etc.): 1. Client 2. Spouse, live-in lover, or domestic companion 3. Minor children of client, spouse, or both 4. Minors in permanent residence and under the permanent care of client or other household member 5. Disabled adults in permanent residence for whom client or other household member has taken permanent responsibilityNumber of people in the household over the age of 18*1234567891011121314151617181920Number of people in the household under the age of 18*01234567891011121314151617181920Does the household receive employment income?* Yes NoEmployment Income*Does the household receive public assistance?* Yes NoPublic Assistance*Does the household receive unemployment?* Yes NoUnemployment*Does the household receive social security?* Yes NoSocial Security / SSI*Does the household receive other income?* Yes NoOther*Other (Source)*Please specify the source of any other income.Does the household have special expenses?* Yes NoSpecial expenses consist of money regularly expended for special needs, such as:Actual payment of support to or for the benefit of persons not included as members of the household;Emplyment required expenses including childcare, transportation, tools and materials, etc.;Actual payments to chapter 13 trustee, installment payments of existing judgments, substantial liabilities, wage deductions, etc.Special Expenses*Total Household IncomeThe following are CVLS' general guidelines for eligibility at 175% of the federal poverty level. Note: We accept bankruptcies for clients at 200% of the federal poverty level. 2020 GUIDELINES Household PopulationTotal Gross Household IncomeWeekMonthYear1$429$1,861$22,3302$580$2,514$30,1703$731$3,168$38,0104$882$3,821$45,8505$1,033$4,474$53,6906$1,183$5,128$61,5307$1,334$5,781$69,3708$1,485$6,434$77,210Each Additional:$151$653$7,840Is the total household income known (include $0)?* Yes NoTotal Income*Please enter the total income for the household.Eligible* Yes NoDoes this client fall within CVLS' financial eligibility guidelines?Explanation of Unknown Income*Important Client InformationCase Type*Select OneAdministrative - EducationAdministrative - Food StampsAdministrative - ImmigrationAdministrative - Incorporation / NonprofitAdministrative - MedicaidAdministrative - MedicareAdministrative - PensionAdministrative - Social Security DisabilityAdministrative - Social Security InsuranceAdministrative - Social Security RetirementAdministrative - TaxAdministrative - UnemploymentAdministrative - Veteran's BenefitsConsumer / Contract - Chapter 7 BankruptcyConsumer / Contract - CollectionConsumer / Contract - ContractsConsumer / Contract - InsuranceConsumer / Contract - UtilitiesConsumer / Contract - Other ConsumerFamily - AdoptionFamily - CustodyFamily - Custody ModificationFamily - Divorce, PetitionerFamily - Divorce, RespondentFamily - Divorce ModificationFamily - Name ChangeFamily - Paternity, PetitionerFamily - Paternity ResponsibilityFamily - Support (initial, non-divorce)Family - VisitationFamily - OtherMiscellaneous | CriminalMiscellaneous | Other MiscellaneousProbate - Descendant's EstateProbate - Guardianship of Disabled AdultProbate - Guardianship of MinorProbate - Powers of AttorneyProbate - WillsProbate - Other ProbateReal Estate - Deed / TitleReal Estate - EvictionReal Estate - ForeclosureReal Estate - Security DepositReal Estate - Other Landlord / TenantReal Estate - Other Real EstateTort - DefendantTort - PlaintiffImmigration Case Type*Adjustment of StatusApplication for Work AuthorizationAsylum, CAT, and Withholding of RemovalDetained Immigrant Bond HearingGuardianship Minor (with SIJS)Special Immigrant Juvenile Status (SIJS)Temporary Protective StatusT VisaU VisaViolence Against Women Act (VAWA)Court Case NumberRace / Ethnicity*Select OneWhiteBlackHispanicNative-AmericanAsianPacific IslanderOtherTwo or MoreCountry of BirthPlease list the client's country of birth if this is an immigration related case.Gender*Select OneMaleFemaleTransgenderOtherHas the client or their family been impacted in any way by incarceration?*Select OneYesNoDisabled?*Select OneYesNo / UnknownBirthdate MM slash DD slash YYYY Military Service*Select OneActiveVeteranSpouse ofDependent ofNoneMilitary Service of Potential ClientLanguageClient's main languageName of InterpreterInterpreter PhoneCase Status InformationDid You: Inform client that you will be reviewing their case for possible representation and that client will hear from you within 3 weeks. Inform client that before you can review the case for possible representation you need additional information or documentation. Provide advice at the interview and inform client that was the only assistance that we could provide. Inform client that they have a meritorious case but that neither you nor another clinic attorney can handle the matter and you will be referring case to CVLS for possible representation.CASE IS OPENCASE IS OPENAdditional Information*CASE IS CLOSEDSummary*Please provide a detailed summary of the client's legal matter, services provided and the outcome.If checked, please send CVLS a case memo, questionaire if used, notes, and copies of any client documents. Email to kkoester@cvls.org. Register As a CVLS Volunteer! Start Making a DifferenceSit down with us and find out what you can do to help your community. ATTEND A VOLUNTEER ORIENTATION
