Chosen Family Law Center Client Intake Questionnaire

This is a secure form. All information will be kept confidential and used only for our internal records. If you prefer not to use this form please call us at 732-639-1657.

Please correct the errors described below.

We are proud to offer assistance to low income residents of NY and NJ who qualify. Please see the list of qualifications for income and geographic location on the right side of this form. If you believe you qualify, please submit the form below and we will get back to you as soon as we can!

(If you do not wish to submit this information here, we can also accept it by telephone.)
(If you do not wish to submit this information here, we can also accept it by telephone.)

FINANCIAL INFORMATION We serve clients up to 250% of the federal poverty line based on household size. Please consult the chart at https://chosenfamilylawcenter.org/income-and-eligibility to determine if you qualify.

For income verification, we will ask you to provide your most recent tax return and W-2 if you have one. If you do not have these, please provide whatever income documentation you have, which could be a paystub or notarized letter from your employer stating your current annual income.
For income verification, we will ask you to provide income documentation (W-2 or tax returns) for your spouse, partner or other household members with whom you share your finances.
Outside of your annual income, please approximate your net worth, which is the total cash value of all your financial accounts and real estate holdings minus your debt. We may ask for documentation of this as well.

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