Eligibility Form – Domestic Abuse Advice

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Legal Aid Eligibility Questionnaire

Section A: Personal Information

Full Name

Date of Birth

Phone Number

Address

Relationship to the Perpetrator:

Current living situation (e.g., living with the perpetrator, living with family/friends, in a shelter, etc.):

Section B: Financial Eligibility

Are you currently receiving any of the following benefits?(Tick all that apply)

Income SupportIncome-based Jobseeker’s AllowanceIncome-related Employment and Support AllowanceUniversal Credit

What is your monthly income before tax?

What are your monthly essential living expenses (e.g., rent/mortgage, bills, food)?

Do you have any savings or valuable assets? If so, please provide details:

Section C: Legal Needs

What type of legal assistance are you seeking? (e.g., divorce, child custody, restraining order, etc.)

Have you previously applied for or received legal aid? If so, please provide details:

Do you have any other sources of legal support or representation? If so, please provide details: