Client Contact Information

Earned Income

How many people reside in your household?

Hourly Wage ($/hr)
Average hours worked per week at this hourly rate
Average weekly tips or other income received for this job

Unearned Income
(Such as unemployment compensation, Social Security, workers compensation, child support or alimony)
Unearned Income Source
Unearned Income Explanation
Unearned Income Amount Monthly

Other Financial Information

Checking / Savings Account Balances
Checking Account Balances
Savings Account Balances

Do you own any of the items listed below?

Description of Legal Matter
Terms and Conditions
If you do not receive a response from us within 1 – 2 business days, please check your spam filter first, then call the Modest Means Legal Program at 603-715-3290.

Please check that your email address and email address confirmation are the same if the Submit Request button is grey, rather than black, and does not generate a "your form has been submitted" page.

For NH-based cases only

To determine whether you qualify for the Modest Means Legal Program, please fill out the form at left. Each referral request is reviewed by an Intake Specialist. Occasionally, additional information may be needed and you will receive an email requesting further details. If you are found eligible for the program, you will be emailed instructions on how to receive a referral by phone or email, depending upon your chosen method of payment of the $25 application fee.

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