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Please complete this form to the best of your ability and hit "submit." After reviewing this form, a representative from the Veterans Legal Clinic will contact you to follow-up. Thank you.

Today's Date

Personal Information:

First Name *

Middle Name

Last Name *

Address *

City *

County *

State *

Zipcode *

Primary Phone (what is the best number to call to reach you? This may be a cell phone, home phone, work phone, etc.) *

Secondary Phone (please provide a back-up phone number we may call that is different from the primary phone number.)

Fax Number

Email *

Date of Birth *

Place of Birth (please provide city and state) *

Sex *

Please Select Male Female

Marital Status *

Please Select Married Widowed Divorced Separated Single

Do you have dependent children? *

Please Select Yes No

If "Yes," what are the names and ages of your dependent children?

Are you currently employed? *

Please Select Yes No

If you are not currently employed, why did you stop working, and when was your last day?

Do you receive any disability compensation from the VA? *

Please Select Yes No

If you are not receiving disability compensation, have you applied?

Please Select Yes No

If you have applied, what was the date of your application?

What language do you prefer to speak? *

Household Income *

Number of people in your household *

Military Service History:

Please list the service dates for each branch of service: *

Discharge Date: *

Characterization of Discharge: *

Please Select Honorable General (Under Honorable Conditions) Other Than Honorable Bad Conduct Discharge Dishonorable Discharge Other

If you selected "Other," please tell us what type of discharge you received:

Legal Issues:

Describe the legal issue for which you are seeking counsel/representation (check all that apply) *

WillPower of AttorneyLandlord/TenantGuardianship/AdoptionFamilyMilitaryEmployment/LaborProbateConsumerOther

Provide a brief description of the issue(s) with which you need assistance: *

What is the desired outcome you hope to achieve through representation? *

Is there an adverse party in this case? *

Please Select Yes No

If "Yes," what is their name and relation to you?

What is their current location (if known)?

Have you previously sought legal counsel from a private attorney for this issue? *

Please Select Yes No

If "Yes," what was the outcome?

Are you currently involved in any other type of civil/criminal litigation or lawsuit? *

Please Select Yes No

If "Yes," of what nature?

What is your role in the litigation/lawsuit?

Please Select Plaintiff Defendant Witness

Have you ever given anyone a power of attorney? *

Please Select Yes No

If "Yes," to whom did you give power of attorney?

Are you facing a pending court deadline? *

Please Select Yes No

Hearing Date and Time:

Filing Deadline

Location of Court

County

Circuit

Have you been served with any notice in the matter?

Please Select Yes No

If "Yes," please describe that information:

By marking “I agree.” below on this application form, I am acknowledging that the information I have provided is true, that I understand that the University of South Carolina School of Law Veterans Legal Clinic is under no obligation to provide me with legal representation, that my acceptance as a client of the University of South Carolina School of law Veterans Legal Clinic is dependent on many factors (including but not limited to my household income, the demands of my legal issue, and available Veterans Legal Clinic resources), that I have the right to seek counsel on my own, and that if I am selected for representation, I will be notified. I acknowledge that the University of South Carolina School of Law Veterans Legal Clinic is not responsible to pay court costs or other fees associated with litigation such as filing fees, expert fees, mediation expenses, and the appointment of a Guardian ad Litem and that I may be required to pay these costs. *

I agree