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.
We are proud to offer assistance to low income residents of New York who qualify. We are no longer accepting New Jersey clients at this time.
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 all of the information required below and we will get back to you as soon as we can!
PLEASE NOTE: By filling out this form you recognize that SERVICES ARE NOT GUARANTEED and/or we may need to place you on a waiting list. Our attorneys are volunteers and there is often a wait for services.
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.
Your information will be encrypted.