Emergency Shelter

If your problem is not an Emergency Shelter problem, use a different application.

MJP will need to speak with you on the telephone or in person.  MJP will need to verify your eligibility for services and may need to gather more information about your situation.

 

If your problem is not a Housing problem, use a different application.
MJP will need to speak with you on the telephone or in person.  MJP will need to verify your eligibility for services and may need to gather more information about your situation.
Completing an Application does not guarantee that you will receive legal help.  Even if you are low-income, our ability to take cases is limited and it may be that the only help we can give you is legal information or referral to self-help materials.• It may take up to seven days to get back to you. 
Your E-mail address
Only provide an email address if you are the only person who has access to it or will be safe if others may see your email.
First name *
Middle name
Last name *
Maiden Name
Alias or Other Names You Go By
Date of Birth *
Street Address *
Address line 2
City *
Zip Code *
Home phone #
Work phone #
Cell phone #
The best phone number for us to call:
      

Is it safe for us to call at this number? *
    

Best time to reach you, Monday through Friday between 9 a.m. and 4 p.m.
Is it safe for us to leave a message at this number? *
    

Please describe here any special instructions or information we need to know concerning how to contact you or the person for whom you are applying for services:
If you are submitting this application for another person, please tell us who you are and what your relationship to the applicant is (family member, service provider, etc.)
Provide the name of the person and / or agency with whom you have the dispute:
Now we need to know how many people are in your household. In answering questions that follow, you must include all persons who are supported by you or who contribute to the support of your household whether or not they are related to you.
How many persons age 18 and older live in your household. (Include yourself)
How many persons under the age 18 live in your household.
What is your race or ethnicity?
Is anyone in this household currently a victim of domestic violence?
    

Have you or anyone in your household served in the military?
    

Household Member Receiving Income *
Income source *
Gross income amount for this source *
How often is this amount received? *
          

Household Member Receiving Income
Income source
Gross income amount for this source
How often is this amount received?
          

Other income information not entered above

Include who receives, from where, how much and how often
Please enter ASSET information for ALL persons in the household *












Value of assets *
How did you hear about us?
My problem is








Date shelter assistance will stop
Date of notice
Reason for this action
Appeal filed
    

Date of hearing
We provide mostly information, referrals, advice and some brief legal help. We do not usually provide representation. In reply to your intake we may: give you information and materials only, or offer some legal advise or brief assistance.
To refer your case for further help or possible representation we need your permission to share information about your case with: Community Legal Aid, or a private volunteer attorney, or other legal Services program that covers your area.
By submitting this application, you agree to these terms.
Enter dollars per hour
How many hours do you work per week?
Enter this number in the monthly column.


Calculator figures "Dollar Per Hour" x "Hours Per Week" x 4.33 weeks in a month.

Income includes, but is not limited to: money, wages, salaries before any deductions, income for self-employment after deductions for business or farm expenses; regular payments from governmental programs for low income persons or persons with disabilities; social security payments; unemployment and worker's compensation payments; strike benefits from union funds; veterans benefits; training stipends, alimony; child support payments; military family allotments; public or private employee pensions; regular insurance or annuity payments; income from dividends, interest, rent, royalties or from estate trusts; and other regular or recurring sources of financial support that are currently and actually available.

Do not include value of food or rent received by you in lieu of wages; money withdrawn from the bank; tax refunds; gifts; compensation and/or one-time insurance payments for injuries sustained; non-cash benefits; and up to $2000 per year of funds received by individual Native Americans that is derived from Indian trust income or other distribution exempt by statue.