Do you have convictions from Skagit, San Juan, or Island County courts?

Name *

First Name

Last Name

Date of Birth *

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Address

Please provide your best mailing address.

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

Please provide the best number to reach you.

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Permission to Text

Yes

No

Financial Eligibility *

Please let us know how you are financially eligible. The applicable Federal Poverty Guidelines for households at the 125% level are provided for reference. 1 person - $18,225 2 people - $24,650 3 people - $31,075 4 people - $37,500 5 people - $43,925 6 people - $50,350 7 people - $56,775 8 people - $63,200

I receive public benefits (check all that apply in the following question)

I receive an annual income, after taxes, of 125% or less of the federal poverty level based on household size.

I receive an annual income, after taxes, of more than 125% of the federal poverty level based on household size but recurring basic living expenses make me unable to pay

I am homeless

I have an acute, chronic, or serious mental illness.

Public Benefits

Please check all of the public benefits your currently receive.

Food stamps or food stamp benefits transferred electronically (EBT)

Medicaid (for example, Apple Health)

Supplemental Security Income (SSI)

Temporary Assistance for Needy Families (TANF)

Aged, Blind, or Disabled assistance benefits (ABD)

Pregnant women assistance benefits

Poverty-related veterans' benefits

Refugee resettlement benefits

Medical care services under RCW 74.09.035

Protected Source of Income

Are any of the following your only source of income?

Social Security Benefits (retirement, disability, etc)

Child Support Payments

Department of Veteran Affairs Benefits

Preferred Language

English

Spanish

Mixteco

Russian

Ukrainian

Other

Race and Ethnicity

American Indian, Alaska Native, or First Nations

Hispanic, Latino/a/x, or Spanish origin

Indigenous to Mexico, Central America, or South America

Black or African American

Afro-Latino/a/x

Afro-Caribbean

Asian

Asian - East Asian

Asian - South Asian

Asian - Southeast Asian

Middle Eastern, (Southwest Asian), or North African

Native Hawaiian or Other Pacific Islander

Slavic/Eastern European

White

More than one race or ethnicity/multiracial

Another race, ethnicity, or origin

Unknown/Prefer not to answer

U.S. Citizenship

We only ask if you are a citizen of the United States in order to keep you safe and to provide competent advice. Your answer is confidential and never shared without your permission. Are you a U.S. citizen?

Yes

No