LSVI Intake Form- English Full Name * First Last Social Security # * Date of Birth * Email Address Place of Birth * Sex * — Select — Male Female US. Citizen * — Select — Yes No Are you or a household member a veteran? * — Select — Yes No Physical Address * Mailing Address * Home Telephone # * Work Telephone # Mobile Telephone # Marital Status * Married Single Divorced Separated Widowed Other Racial Ethnicity * Black White Hispanic Native American Asian or Pacific Islander Other Who is your complaint against? * What is the mailing and physical address of the person your complaint is against? Have you ever been the victim of domestic violence? — Select — Yes No Has a restraining order every been issued against you? — Select — Yes No Number of children (under 18 years of age) living in your home: If there are children living in your home, please list each child's name, age, and school attending below. Number of adults (18 and over) including yourself living in your home. Please list each adult's name, age, employer, salary and salary frequency below. Please indicate any additional income received in your household: TANF (Welfare) Workmen's Comp Social Security Child Support Unemployment Retirment/Pension Alimony Veteran's Benefits Rental Income Do you or other members of your household have other assets, such as savings and checking accounts or stocks & bonds? * Savings Account $ Checking Account $ Stocks/Bonds $ Other Real Property: Do you own or rent your home? — Select — Own Rent What is your monthly payment? Do you own property other than your residence? — Select — Option If yes, where is it located? Do you own any car, truck or motorcycle? — Select — Yes No If yes, please decribe each vehicle. How much is each vehicle worth? How much is owed on it? Do you have any medical expenses? — Select — Yes No Do you have any other debts? — Select — Yes No If yes, please list the type of debt (Medical, Loans, Childcare, etc.), payment amount and payment frequency (ie. weekly, bi-weekly, monthly , yearly). By typing my name below, I attest that all of the information I have provided on this form is true and correct. By typing my name below, I certify that I am a citizen of the United States.