Part 1 Your Information
First Name
Middle Name
Last Name
Suffix
Other Name(s), Previously Used e.g. Maiden Name? Foreign Name?
Preferred Name
Date of Birth
Month Date Year
Social Security Number *** - *** -
Last 4 digits only, if applicable
City/Zip Code
How long have you lived in
Number of Years and Month
the United States? -or-
Date of Entrance to the United States
Number of Years and Month
California? Any other State(s)? -and-
Please Specify State(s)
Email
Phone Number
Is it safe to contact directly via:
➲Calls? Yes No
➲Text Messages? Yes No
➲Voicemails? Yes No
➲Via Email? Yes No
Preferred way to be contacted (Please, indicate) ➲
Preferred Language English Russian Other
Translation Yes No
If yes, please specify language, purpose, documents, etc.
Interpreter Yes No
If yes, please specify language, purpose, types of communication, court hearings, etc.
(Cont’d)
1
C opyright © 2022 R usC rane L aw F irm , A .P .C . A ll R ights R eserved ⏐ www.ruscranelaw.com
Part 2 Income Information
Please understand you might be asked to provide proof of eligibility based on the responses you provided (For example, produce
necessary documentation to verify family size and/or income). Below should indicates the total amount of funds from all the following
sources (before taxes and deductions) you personally (and/or your household) receive per month (including the financial assistance
under one or more of the following programs).
Employment
(Type or Industry) (Part-time or Full-time)
Unemployment
Spousal Support
Alimony
Child Support
Pension
Retirement
Social Security
California Food Assistance Program
CalFresh or Snap (Both Are Generally known as Food Stamps)
CalWORKs
California Work Opportunity and Responsibility to Kids Act
Country Assistance
County Relief, General Relief “GR” or General Assistance “GA”
SSP State Supplemental Payment
SSDI
SSI Supplemental Security Income (not Social Security)
IHSS
In-Home Supportive Services
CAPI
Cash Assistance Program for Aged, Blind, or Disabled Legal Immigrants
Other (Specify)
How do you support yourself?
(Provide a short narrative below and include any life difficulties you may consider relevant)
(Cont’d)
Please note RCLF does not and shall not discriminate on the basis of race, color, religion (creed), gender, gender expression, age, national origin (ancestry), 2
disability, marital status, sexual orientation, or military status, in any of its activities or operations. These activities include, but are not limited to, hiring and
firing of staff, selection of volunteers and vendors, and provision of services. RCLF is committed to providing an inclusive and welcoming environment equally for
all members of our staff, clients, volunteers, subcontractors, vendors, and clients.
C op yright © 2022 R usC rane L aw F irm , A .P .C . A ll R ights R eserved ⏐ www.ruscranelaw.com
How many adults (18 years and older) other than yourself depend on your income?
How many children (18 and under) depend on your income?
Your household size (how many persons are in your family)
Part 3 Your legal issue information
If you are not already a client of RCLF please do not send confidential information other than personal information above until
you’ve received a response about your eligibility and made a direct contact with an attorney. If you are a current client, please
directly contact your attorney with respect to the matter.
If you have multiple issues, it may be necessary to re-determine your eligibility and schedule a follow-up or separate session.
Case?
Open Case?
What courthouse is your case located?
Any upcoming court dates?
Any upcoming document submission(s)?
Have you consulted any attorney for this matter?
Have you consulted any legal service provider(s)?
Do you consent for RCLF contact the whom previously consulted?
Yes No
Attorney for the other side?
READ CAREFULLY BEFORE SIGNING BELOW: I have reviewed the information provided above and responded truthfully, completely, and
accurately to the best of my knowledge. I understand the financial eligibility requirements for legal services will be determined based on the
responses I have provided in this form. I have signed this form under the penalty of perjury and my signed form is to be submitted to RusCrane
Law Firm A.P.C. (“RCLF”) for RCLF to determine my eligibility for the legal services to be provided. I understand RCLF cannot guarantee that
it will be able to find an attorney to assist with some or all my legal matters. Further, I understand the submission of this form and the responses
herein provided to RCLF does not mean the RCLF is my attorney and does not establish an attorney-client relationship even if I am financially
eligible to receive the legal services, until certain specifications are met and I am accepted as Client of RusCrane Law Firm A.P.C. Prior to an
attorney-client relationship RCLF completes a conflict check, discusses legal situation and the merits of a case to the extent possible, discusses
the terms and conditions of the legal services and representation to be agreed upon and executes a written Retainer Agreement signed by Attorney
and Client.
[Name]
[Signature]
[Date]
Please note RCLF does not and shall not discriminate on the basis of race, color, religion (creed), gender, gender expression, age, national origin (ancestry), 3
disability, marital status, sexual orientation, or military status, in any of its activities or operations. These activities include, but are not limited to, hiring and
firing of staff, selection of volunteers and vendors, and provision of services. RCLF is committed to providing an inclusive and welcoming environment equally for
all members of our staff, clients, volunteers, subcontractors, vendors, and clients.
C op yright © 2022 R usC rane L aw F irm , A .P .C . A ll R ights R eserved ⏐ www.ruscranelaw.com
