Application Form

All fields marked with * are required.

Client First Name *

Client Middle Name

Client Last Name *

Client Suffix

Client Date of Birth

Client Race

Client Gender

Pronouns

LGBTQIA Status

Are there any special circumstances you'd like us to know about? Tell us your story--we want to help however we can.

OCA Number

Case Number

Charges

Charge Type

Arrest Date

Total Bail Amount

Has the attorney requested a bail reduction?

Initial Bail Amount (if applicable)

Reduced Bail Amount (if applicable)

At your bail hearing, did the judge/commissioner ask about your ability to pay?

Next Court Apperance Date

Facility where person is held

Supervision

Any Prior FTA?

Does the person have a driver's license?

Is this person experiencing homelessness?

Client Phone Number

Client Email Address

Community Contact 1 - Name

Community Contact 1 - Relationship

Community Contact 1 - Phone Number

Community Contact 1 - Email Address

Community Contact 2 - Name

Community Contact 2 - Relationship

Community Contact 2 - Phone Number

Community Contact 2 - Email Address

Attorney Name

Attorney Phone Number

Attorney Email Address

Your Name *

Your Relationship To The Client *

Your Phone Number *

Your Emai Address *

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