ENE SERVICE FEE ADJUSTMENT REQUEST
ENE SERVICE FEE ADJUSTMENT REQUEST
Name: ____________________________________ Date of Request: ______________________
Name of Evaluator(s):________________________
I. PLEASE COMPLETE THE FOLLOWING:
1. ______ I am currently eligible for and am receiving public assistance, (MFIP, GA, MA, MSA, SSI, or food stamps).
2. ______ I am currently eligible to receive legal services from LASNEM (Legal Aid Services of NE Minnesota) or the Volunteer Attorney Program.
OR
_____________________________________________
II. IF NONE OF THE ABOVE APPLY AND YOU WANT CONSIDERATION FOR FEE ADJUSTMENT, PLEASE COMPLETE THE FOLLOWING:
______ How many children in your household/family? (minors only)
______ Monthly gross income?
______ Source of income: wages, self-employment, unemployment, workers comp, RSDI, veteran’s benefits, other___________________
______ I own the following property (please fill in the value for each):
_____ cash
_____ checking, savings, credit union accounts
_____ cars, other vehicles (equity value = market value minus unpaid loan)
_______ type $__________
_______ type $__________
______ Real Estate which I own or am part owner
______ homestead value (equity)
______ other
______ Unusual medical expenses or other emergencies you want us to consider:
____________________________________________________________________
______ If self employed:
______ Tools, machines, office furniture, accounts receivable, inventory reasonably necessary in your trade or business (value)
______ Lawsuit settlement proceeds pending, if so, anticipated amount____________________
______ Other:__________________________________________________________________
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