Apply for Legal Services

Your Email Address:

Only provide an email address if you are the only person who has access to it.If other people have access to the emails that you receive, please leave this field blank.

First Name: *

Please enter the first, middle, and last names of the person applying for legal services in the fields provided.

Middle Name: *

Last Name: *

Date of Birth: *

Month

Day

Year

Street Address: *

Address Line 2:

City: *

State *

Zip Code:

Home Phone:

Work Phone:

Cell Phone:

What is the best phone number for us to call? *

Home

Work

Cell

Is it safe for us to call at these numbers? *

Yes

No

Is it safe for us to leave a message at these numbers? *

Yes

No

What is the best time to reach you Monday-Friday between 9am and 4pm? *

We'll need to contact you on a week day during our business hours. Tell us what time between 9am and 4pm would be most convenient for you.

Please describe any special instructions or information concerning how to contact the person applying for services

If you are submitting this application for someone other than yourself, then please let us know who you are and tell us about your relationship to the applicant (family member, service provider, etc.)

Select the legal topic that most closely matches your problem *

Provide the name of the person with whom you have the dispute *

Birth date of the person with whom you have this dispute - if known

Month

Day

Year

Please select from the list below the issue that most closely matches the problem you are seeking help with *

If you are in fear for your safety, this on-line application is not suitable to address your immediate needs. Please call 911 if this is an emergency, or call the Statewide Domestic Violence Hotline for immediate support: 1-866-644-3574.

Has a court made any orders about this issue before? *

Yes

No

Are you trying to change an existing court order? *

Yes

No

Has this case already been filed by you or by your opponent? *

Yes

No

Please select from the list below the issue that most closely matches the problem you are seeking help with: *

What kind of housing is this issue about? *

Rented Apartment

Rented Room

Rented Single Family Home

Rented Mobile Home

Rented Lot in Mobile Home Park/Mobile Home Owned by Tenant

Rented Condominium

Rented Vacation Unit Used as your Residence

What is your landlord's name? *

Please state how many rental units your landlord owns, if you know:

Does your landlord live in your building? *

Yes

No

What is your landlord's address?

Did you sign a lease?

Please describe any written notices from your landlord or someone acting for your landlord and include the date you received it:

List any deadlines:

Do you have a hearing date? *

Yes

No

When is your hearing? *

Month

Day

Year

At which court will your hearing be held? *

Briefly describe the legal problem; it does not need to be a long description: *

Has anything been filed in Court? *

Yes

No

Date of home purchase

Month

Day

Year

Enter approximate date if actual date is unknown.

Original purchase price $

Current monthly payment amount for 1st mortgage $

Is insurance included in this payment?

Yes

No

Are property taxes included in this payment?

Yes

No

Amount and/or number of months behind

Property's assessed or Fair Market Value $

Balance due on 1st mortgage $

Amount of 2nd Mortgage payment $

Amount and/or number of months behind on 2nd mortgage

Balance due on 2nd mortgage $

Do you owe property taxes that are past due?

Yes

No

Property tax liens - if so, list by year

Other liens - please specifiy

Name of mortgagee seeking to foreclose

Date notice of foreclosure received

Month

Day

Year

Is a foreclosure sale scheduled?

Yes

No

If sale is scheduled, please enter date

Month

Day

Year

Has applicant filed bankruptcy before?

Yes

No

Date bankruptcy case filed

Month

Day

Year

Bankruptcy chapter filed

7

13

Do you want to save the home, and if so do you have a realistic plan to maintain it? Please explain briefly.

Are you willing to sell the home

Yes

No

Spouse/Partner

Children/deceased children (and issue) – include for each

Name, date of birth, child’s other parent (if not spouse/partner)

For any deceased include date of death and names and ages of decedent’s issue

Other Heirs

Please list names and addresses of parents and siblings

List any prior marriages including date of death or divorce

Please identify any remaining divorce issues.

Identify any dependents

Identify any existing estate planning documents

List major mortgages, notes, credit card obligations or other debts

Please check all of the following that you own – in whole or in part

Are you seeking or receiving disability benefits from

the Social Security Administration (SSA)

NH Dept of Health & Human Services (HHS)

Both SSA and NH Dept of HHS

Have you filed an application?

Yes

No

For what program(s) have you applied? (check all applicable)

Social Security Disability Insurance (SSDI) – from SSA

Supplemental Security Income (SSI) – from SSA

Aid to the Permanently and Totally Disabled (APTD) – from HHS

Have you received a decision?

Yes

No

Were you denied?

Yes

No

If so, for which program(s) were you denied?

SSDI

SSI

APTD

What is the date of the denial?

Month

Day

Year

If more than one, write in additional dates here:

Have you filed an appeal for each denial?

Yes

No

Do you have a hearing scheduled?

Yes

No

If so, what is your hearing date?

Month

Day

Year

If you have more than one hearing date, write in additional dates here:

Very briefly, what is the nature of your disability or disabilities?

Are you receiving medical or mental health treatment for those conditions?

Yes

No

Date you were last employed?

Month

Day

Year

If you have not been denied disability benefits, briefly describe your legal problem here:

Have you received written notice of an overpayment?

Yes

No

I am not sure

What is the date of the notice?

Month

Day

Year

What is the amount of the overpayment? $

When does the notice say the overpayment occurred?

Month

Day

Year

How does the notice say that the overpayment was caused?

Do you agree with the facts in the notice?

Yes

No

Has Social Security started withholding benefits to pay back the overpayment?

Have you filed an appeal or a request for reconsideration?

Yes

No

If you don’t believe an overpayment occurred, or think the amount is too high, you may have filed an appeal or a request for consideration.

If you filed an appeal or request for reconsideration, when did you file?

Month

Day

Year

Have you filed a waiver request?

Yes

No

If you filed an waiver request, when did you file?

Month

Day

Year

Briefly, what else do you think we need to know about this alleged overpayment?

When did you apply for benefits?

Month

Day

Year

In which office did you apply?

What is the name of the company you worked for?

How long did you work for them?

What is the last day you worked?

Month

Day

Year

How did you end up losing your job?

I quit

I was laid off

I was fired

Why did you quit, get laid off or fired?

When did you apply for Unemployment?

Month

Day

Year

What is the date of the denial letter?

Month

Day

Year

What is the reason for denial?

Have you filed for an appeal?

Yes

No

If you have a hearing date, what is it?

Month

Day

Year

Have you continued to file claims?

Yes

No

IMPORTANT: you will not get benefits for any week for which you do not file. Keep filing while you wait for the appeal.

Are you looking for work?

Yes

No

You must continue to meet the job search requirements while you wait for the appeal.

Have you received written notice of an overpayment?

Yes

No

What is the date of the notice?

Month

Day

Year

Have you filed an appeal?

Yes

No

If you filed an appeal, when did you file it?

Month

Day

Year

What is the amount of the overpayment? $

When does the notice say the overpayment occured?

Month

Day

Year

What reason does the notice give for the overpayment?

Do you agree with the facts in the notice?

Yes

No

I am not sure

Are any benefits being withheld to repay the overpayment?

Yes

No

I do not know

What type of legal case do you have?

Please select one that most closely matches the type of case you are seeking help with.

Agency and Other Referrals

If you were referred to us, please let us know who referred you. If you are referring the above referenced person to us, let us know who you are and how to reach you. Thank you.

The number of people who live with you under the age of 18 *

Include yourself if you are under 18 years of age.

The number of people who live with you over the age of 18 *

Include yourself if you are over 18 years of age.

What is the total yearly income of all members of your household? * $

Add up how much you and the other people who live with you earn in a year, before taxes are taken out.

The income listed above is received *

How did you hear about this application?

Are you a US Citizen? *

Yes

No

Non-citizens may still be eligible for services, but we might need more information about your status. No information we gather is shared outside of the legal services agencies without your permission.

Are you, or is a member of your household, a veteran? *

Yes

No

New Hampshire Legal Aid

Legal Information, Referrals, and Pro Se Assistance

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