Domestic Violence Application

If you or someone you know are a victim of domestic violence and are seeking assistance for your domestic violence case, please complete the form below.  If you do not know the answer to a question please type N/A.  If you need assistance completing the application please contact  Wendy Arauz warauz@dadelegalaid.org or Luisa Pena lpena@dadelegalaid.org.

If you feel that you are in immediate danger call 911. 

Case Information

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Petitioner's (Your) Information

Name(Required)
Address(Required)
Is this a Home or Cell#(Required)
When is the best time for us to reach you via telephone?
Is this a Home or Cell#
MM slash DD slash YYYY
If you do not have a social security number, please enter 9 zeros.
Select N/A if you do not have a Social Security #
Do you speak English?(Required)
Citizen Status(Required)

Employment

Pay frequency
Are you presently receiving child support?
Do you own any Real Estate?
Do you have a criminal record?
Have you ever had a drug or alcohol problem?
Have you ever been diagnosed with a mental health problem?
Has COVID affected your everyday life in the following ways: loss of job, financial hardships, medical issues, etc?
DO YOU NEED SPECIAL ACCOMODATIONS TO PARTICIPATE IN THE PROGRAM?

Demographics

Ethnicity(Required)
Marital(Required)
Are you a veteran?

Information

Have you met with another attorney about this matter?
Are you presently being represented by an attorney?
Have you been reported to DCF for child abuse?
Have you ever obtained a restraining order against the Respondent (Abuser)?

Children

DO YOU HAVE MINOR CHILDREN WITH THE OTHER PARTY?(Required)
If Yes, please enter the name and date of birth for each child on one line
Name
Date of Birth
 
ARE THERE OTHER CHILDREN LIVING IN THE HOUSEHOLD?(Required)
If Yes, please enter the name and date of birth for each child on one line
Name
Date of Birth
 

Adults

ARE THERE ANY OTHER ADULTS LIVING IN THE HOUSEHOLD?(Required)
If Yes, please enter the name and date of birth for each adult on one line
Name
Date of Birth
 

Respondent's (Abuser) Information

This field is hidden when viewing the form
MM slash DD slash YYYY
if you do not know the Resp DOB, please enter 00/00/0000
Respondent's Name(Required)
if you do not know the Resp DOB, please enter 00/00/0000
Respondent's Address

If you do not know the respondent's phone numbers, please enter 0's for the phone numbers and select "Do not have respondent's number"

Is this a Home or Cell #?
Is this a Home or Cell #?
Pay frequency
Is Respondent presently paying child support?
Do you and Respondent own a home, apartment, mobile home or land (whether or not is located in the United States)?
Respondent's Ethnicity(Required)
Do they speak English?(Required)
Is Respondent a U.S. Citizen?(Required)
Does Respondent (Abuser) have a criminal record?(Required)
Has the Respondent (Abuser) ever had a drug/alcohol problem?
Has the Respondent ever been diagnosed with a mental health problem?
Does the Respondent (Abuser) own a firearm?
Is the Respondent presently being represented by an attorney?
Has the Respondent ever been reported to DCF for child abuse?
Has the Respondent ever obtained a restraining order against you?
Has someone else, other than yourself, ever obtained a restraining order against the Respondent?
APPLICANT’S CERTIFICATE

THE ANSWERS AND INFORMATION PREVIOUSLY STATED BY ME IN THIS APPLICATION ARE TRUE, AND I ASK DADE LEGAL AID DOMESTIC VIOLENCE PROJECT TO RELY ON THEM.
I AGREE THAT:

Please Check off each section below that you understand & agree.(Required)
MM slash DD slash YYYY
Clear Signature
My position in the case will be(Required)

I understand that Dade Legal Aid (DLA) may receive litigation assistance from other attorneys or persons, and I hereby authorize DLA’s attorney to consult with them as needed.

*I understand that I claim to be indigent (not applicable to Domestic Violence victims) and should my financial status improve significantly during the course of DLA’s representation or if my ward’s financial status improves (in the case of Guardianship), I will advise DLA, which will petition for reasonable fees and costs. I understand that during the course of DLA’s representation, it may request, and I shall provide, all financial information, including, but not limited to, real estate owned, pay stubs, and income tax returns. Furthermore, DLA reserves the right to seek attorney’s fees and expenses from the adverse party to the client. DLA may or may not seek fees, at its discretion. Fees are calculated by the lodestar method, which is the number of hours of work performed, times a reasonable hourly method. The rate of your attorney is $300.00 per hour.

COSTS: I understand and agree that I am responsible for all costs of translators, court reporters, and filing fees (if required) in advance, or at the time of service.

NO GUARANTEE OF RESULTS: Nothing in this Retainer Agreement says or implies that the client will win his/her case.

ASSISTANCE TO BE PROVIDED: DLA agrees to provide you with the following legal assistance: To fully represent your interests within the guidelines of the Florida Code of Professional Conduct, while keeping your matter confidential, unless you agree otherwise. DLA will not take significant action, such as settling your case or going to trial, without your prior approval.

WITHDRAWAL: DLA may withdraw as my attorney, in the event of irreconcilable differences or inability to contact the client.

 

MM slash DD slash YYYY

The undersigned hereby understands and acknowledges, that an interview and/or consultation with a Legal Aid attorney, does not mean that Dade Legal Aid will represent them. If and when Dade Legal Aid does represent them at a future date, the undersigned understands that Dade Legal Aid will only represent them at their Permanent Injunction Hearing and no other court hearings that may arise from the final Permanent Injunction Hearing.

Clear Signature
Name(Required)
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