Modest Means Legal Program Prequalification Form


For NH based cases only

To determine whether you qualify for the Modest Means Legal Program, please fill out the form below. 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.

Client Contact Information

Earned Income

How many people reside in your household?


Please list income from ALL wage earners in your household, regardless of their involvement in your case.


Hourly Wage ($/hr)

Average hours worked per week at this hourly rate

Average weekly tips or other income received for this job

Job 1:

Job 2:

Job 3:

Job 4:

Please list any additional earned income, including gross salary wages not listed above:

Unearned Income

(such as unemployment compensation, Social Security, workers compensation, child support or alimony)

Unearned Income Source


Unearned Income Explanation

Unearned Income Amount per Month

Unearned Income 1:

Unearned Income 2:

Unearned Income 3:

Please list any additional unearned income:

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

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.

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