Financial Eligibility Questions

Demographic Information

Date of Birth

Driver's License Number

Social Security Number

What are your social media handles?

Please add social media handles for Facebook, Instagram and Twitter. You should answer n/a if you do not use social media.

Are you a US Citizen?

Yes

No

Are you a Legal Resident?

IF YOU ARE AN ELIGIBLE LEGAL RESIDENT ALIEN, PLEASE STATE WHAT DOCUMENT AND/OR PROOF THAT YOU ARE ABLE TO PROVIDE ECI CONTAINING YOUR UNITED STATES CITIZENSHIP AND IMMIGRATION SERVICES STATUS.

Gender Identity

Select an Option Male Female Transgender Nonbinary Prefer Not to Say

Race

Select an Option Asian/Pacific Islander Black or African American Hispanic Indian Native American Other Race White

Language(s) Spoken

EnglishSpanishVietnameseUrduAlgonquianCherokeeChineseFarsiFrenchIroquoisMandarinNavajoPersianRussianSign Language

Marital Status

Select an Option Single Married Separated Divorced Widow(er)

Highest Educational Level Completed

Select an Option Did not complete high school High School Diploma Some College Associates Degree Bachelors Degree Graduate Degree Doctoral Degree Professional Degree Other not listed

How were you referred to ECI?

Fort Bend County County Law Library

TSU or TMSL Student or Employee

Please state the name of the TSU or TMSL Student or Employee

Court and/or Judge

Please list the court number and location and/or judge

Other

Please list the other referral source

A Month of Service Presentation (AMOS)

Friend or Relative

Please provide the name of your friend or relative

Other Legal Services Provider

Please provide the name of the legal services provider who referred you

Media or Advertisement

Please provide the name of the media outlet or advertiser

Government Official

Please provide the name of the government official

Church or Religious Group

Please list the name of church or religious group

Houston Bar Association

Houston Lawyers Association

NAACP

Harris County Tax Office

Harris County Appraisal District

Houston Volunteer Lawyers

Are you a victim of domestic violence?

Yes

No

Are you disabled?

Yes

No

Are you a veteran?

Yes

No

Are you a member of the LGBTQ community?

Yes

No

Have you been involved in the foster care system?

Yes

No

Are you homeless?

Yes

No

Are you currently confined to jail or prison?

Yes

No

Are you currently represented by an attorney?

Yes

What attorney or legal service provider is assisting you with this case?

Please provide the name and phone number of the attorney

No

Estate Planning Section

Do you currently have a will?

Yes

If yes, what is the date of the will? Was the will signed in Texas? Amended will or codicil?

No

Beneficiaries

Please list all of the beneficiaries of your estate.

Spouse

Please list the name, date of birth, and social security number, of your spouse if you would like for him/her to inherit from your estate.

Please list the full name of your current spouse. If you are not married or do not want your spouse to inherit from your estate, please enter "N/A" here.

What is your spouse's address, including the county? What is your spouse's phone number? What is your spous's email addess? Is your spose a US citizen?

Children

Please list the name(s), ages and relationship of your child(ren).

Please include the names, ages and relationship of ALL of your children, whether or not you want them to inherit from your estate. If you do not have children, please enter "N/A" here.

Please list the names of any children who you want to disinherit.

If you have children that you DO NOT want to inherit from your estate, please list them here. If this does not apply to you, please enter "N/A" here.

Other Beneficiaries

Please list any other beneficiaries of your estate.

Please list others who you want to inherit from your estate. This could include living parents, siblings, grandchildren, other relatives, friends and/or organizations, etc.

Distribution of Property and Estate Management

Distribution of Property

Please list all property and the beneficiary who you would like to inherit each item.

Are all of your beneficiaries over the age of 18?

Yes

No

If a beneficiary is under the age of 18, please list the name of the minor beneficiary here.

A minor is defined as a person under the age of 18 years.

Who do you wish to be the executor of your estate? Please include the person's name, relationship, address, phone and email address.

The executor is the person responsible for distributing your property after your death.

Who do you wish to be the alternate executor of your estate? Please include the person's name, relationship, address, phone and email address.

An alternate executor becomes the executor if the executor is either unwilling or unable to serve as executor.

Who do you wish to be the trustee of your estate?

The trustee is the person who will be responsible for the long term management of property for the surviving spouse, children or other beneficiiaries.

Who do you wish to be the guardian of your minor children?

The guardian is the person who will take physical care of your minor children should both parents die.

Funeral Arrangements

Describe any funeral arrangements to be included in the will:

Power of Attorney

List the name, address and phone number of the person who you want to serve as your power of attorney

the person who will be responsible for handling your financial affairs in the event you become incapacitated..

List the name, address and phone number of the person who you want to serve as your alternate power of attorney.

List the name, address and phone number of the person who you want to serve as your healthcare agent.

The guardian is the person who will make medical decisions for you in the event you are unable to make them for yourself.

List the name, address and phone number of the person who you want to serve as your alternate healthcare agent.

List the name, address and phone number of the person who you want to serve as your HIPPA authorized agent.

the person who is authorized to receive your medical information from a health care provider.

List the name, address and phone number of the person who you want to serve as your alternate HIPPA authorized agent.

Additional information not included elsewhere.

ACKNOWLEDGMENTS

THE INFORMATION PROVIDED IS A TRUE AND ACCURATE STATEMENT OF MY FINANCIAL SITUATION (INCLUDING THE INCOME OF ALL FAMILY MEMBERS WITH WHOM I RESIDE) AND THE FACTS CONCERNING MY PROBLEM.

Yes

No

I confirm that I have named all persons who I believe have an interest in my case. I understand that if a conflict of interest arises from the facts of my case, my case will be closed.

Yes

No

I confirm that everything submitted and stated within this application is true.

Yes

No

I confirm that I have watched and reviewed the information contained on the Earl Carl Institute website provided to assist me with completion of estate planning documents.

Yes

No