ࡱ> FHE bjbjO O 46-a-a nn8,@\T"$@ PPPjPPP/{XFG$0TO,v!@vv!{v!{D"PTv!n :  SEQ CHAPTER \h \r 1 Pittsburgh Pro Bono Partnership Custody Conciliation Project If you are an individual with a low income, you may be eligible for a pro bono (free) attorney from the Custody Conciliation Project. This project is open only to individuals and families who meet the low-income guidelines of the program. Please read the following information carefully. To determine your eligibility for this program, you must do the following: 1. Complete the information requested on the attached application form. PLEASE PRINT. 2. Place the self-assessment form in the drop box in the Custody Department, Suite 1030 on the 1st floor of the Family Court building. You must do this at least 10 days before the date of your conciliation or you will not be eligible for an attorney. If you are eligible for the program and if an attorney is available to represent you, you will receive a telephone call from the attorney assigned to your case. You must leave a contact number at which a message can be left. If you are not available when the attorney calls and a message is left, you must return the call within 24 hours. If you do not follow these instructions, the attorney is not required to represent you. The attorney will be entering a limited representation for the conciliation ONLY. The attorney will not represent you in any other custody proceedings. If it is determined that you are not eligible for the program, you will receive a letter stating the reason why you are not eligible. CUSTODY CONCILIATION ATTORNEY APPLICATION FORM Complete the following information. PLEASE PRINT. IF YOU DO NOT COMPLETE THE INFORMATION FULLY AND ACCURATELY, YOUR FORM WILL NOT BE PROCESSED. Case Docket #____________________ Name: SSN: Address: City: State: Zip: Telephone number(s) where message can be left: Date of conciliation: Time of conciliation: Name of Other Party: Complete the chart in full below to show TOTAL HOUSEHOLD INCOME. You may be asked to provide proof of your income. Give names, ages, and income of all household members. HOUSEHOLD INCLUDES: a spouse or someone living with you with whom you have a child, and children under 21 years old. HOUSEHOLD DOES NOT INCLUDE: parents, brothers or sisters, or someone living with you with whom you do not have a child. Income includes income from employment, self-employment or unemployment or workmens compensation; public assistance (TANF or General Assistance); Social Security (including SSI and SSD); spousal or child support; assistance from family members; pensions of any kind; veterans benefits. To calculate income from hourly wages, use the following formula: X = X 4.3 = Rate per hour Hours worked per week Total weekly income Total monthly income NAME RELATIONSHIP AGESOURCE OF INCOMETOTAL MONTHLY INCOME  MyselfSpouse/OtherChildChildChild TOTAL HOUSEHOLD MEMBERS: TOTAL HOUSEHOLD INCOME:  HYPERLINK http://www.nlsa.us) I hereby certify that, to the best of my knowledge, the eligibility information contained in this self-assessment form is true, correct, and complete. If I am assigned an attorney, I agree to report any changes in circumstances immediately. Date: Client Signature:     YZ[\jtr^M?.?. hPthPtCJOJPJQJaJhf/CJOJPJQJaJ hPthPtCJOJPJQJaJ&hPthPt5>*CJOJPJQJaJ#hPthPt5CJOJPJQJaJ&hPthPt5>*CJ$OJPJQJaJ&hPthPt5>*CJ OJPJQJaJ)jhPthPtCJOJPJQJUaJ hPthPtCJOJPJQJaJ/jhPthPt5>*CJOJPJQJUaJ)jhPthPtCJOJPJQJUaJ 9YZ[ ' ( $ & p q $0d1$]^`0a$gd $d1$]^a$gd $d1$]^a$gd $1$]^a$gd & *   & ' ( ' ) K Q p 'ܲ܏}kkWܲC&hPthPt5>*CJ OJPJQJaJ &hPthPt56CJOJPJQJaJ#hPthPt>*CJOJPJQJaJ#h hPt>*CJOJPJQJaJ#hPthPtCJH*OJPJQJaJ hPth CJOJPJQJaJhPtCJOJPJQJaJh CJOJPJQJaJhf/CJOJPJQJaJ hPthPtCJOJPJQJaJ#hPthPt6CJOJPJQJaJ ()x1g/0 h0d1$^`0gdPt hd1$gdPt dh1$gdPtPdh1$^P`gdPt d1$gdPtpd1$^p`gdPt$d1$a$gdPt'(N[$(-0_f|/0gy۽۩۩۩۩۩۩۩۩۩۩۩۩ۗ||hPthPt>*OJPJQJhPthPtOJPJQJ#h hPt5CJOJPJQJaJ&hPthPt5>*CJOJPJQJaJhPt5CJOJPJQJaJh 5CJOJPJQJaJ#hPthPt5CJOJPJQJaJ#hPthPt5CJ OJPJQJaJ *0gVs d-$1$IfgdPt dT$1$IfgdPtd-$1$IfgdPtdT$1$IfgdPt dgdN& d1$gdPt h@d1$^gdPt & F h@@d1$`gdPt ,-HIJKL̺̟̟̟̟̟̟oo^o^ hPt5>*CJOJPJQJaJ&hPthPt5>*CJOJPJQJaJ#hPthPt5CJOJPJQJaJhPtCJOJQJ hPthPtCJOJPJQJaJhACJOJQJ#hPthPt>*CJOJPJQJaJ hPthPtCJOJPJQJaJ#hPthPt>*CJOJPJQJaJ hPthPtCJOJPJQJaJ:kd $$Ife4r <D% Tv04 eaef4yt$ dT-$1$IfgdPt<kd $$Ife4r <D% Tv04 eaef4yt$ dT-$1$IfgdPtdT-$1$IfgdPtdT$1$IfgdPtN<<<<<dT-$1$IfgdPtkd $$Ife4r <D% Tv04 eaef4yt$ N<<<<<dT-$1$IfgdPtkd $$Ife4r <D% Tv04 eaef4yt$  N<<<<<dT-$1$IfgdPtkdi $$Ife4r <D% Tv04 eaef4yt$ LobND999 d1$gdPt dgdN&kd=$$Ife4r <D% Tv04 eaef4yt$ LMklmno`iٿꤍ{i[iSOSOSOSOihjjhjUhPtOJPJQJ^JaJ#hPthPt>*OJPJQJ^JaJ#hPthPt5OJPJQJ^JaJ,hPthPt>*B*OJPJQJ^JaJph5jhPthPt>*B*OJPJQJU^JaJph3jhPthPtCJOJPJQJU^JaJ hPthPtOJPJQJ^JaJ)jhPthPtOJPJQJU^JaJbc dgdPt Pdh1$^`PgdPt dh1$gdPt 21h:pPt/ =!"#$%  DdEj  C FA.PGHprobonoPartnerlogo2bW Vد8˝t:%b3 Dn+ Vد8˝t:%bPNG  IHDRkfPLTELLLyyy鼼nnnޱWWWbbbȄs۸pҦLլXܸഁbbBBРزeǡ}##ѱʔ֬޾|33rrĈRRϠ@jOǞ3tRNSqbKGD2@L cmPPJCmp0712HsIDAThCv6F0Ud[um?\fE+sE 0i&jA#);U_}}|o[ꚞl]_x>[,)/P>fsun@qSSsޗ6κ?& D ˓c#̘w`>ab4J%9Ⱥp%A}__1!֙Q4l8aTY-( FiY/HAYC-lt^bur10%>֫L1L5ҿXAmzeJO0k?UQ4f@IL ]ce@b@YzW{z°6Fk3FYہYo5ӃNĞ=Yvy<hwvzV,XfvV՜p;fR쥯MMN4QLϊXcuִjt}_]5;B‘C [<4#GP!ě)FȇqUC"+ <\:cV4pY WQèB=X<)@$ScҐ"@UD9hYܓa Bŀ>KfYOS #Nŋ"1-u \B6WC~,'ȚESTł3G`E,aIJAy\ãU\W"Qe% KKʠ n) q[( $]JΡFJZR41_\`d?_9x& 8j=5 6}*UiB̂)fqT0F<D!U6!eARbFv.caB/ ::Q,:KazDUEm؅*$R)V-B5$lGT a[,N[ pE7n.)P"m"qV9>v=MdǑ6IENDB`$$Ife!vh#v #vT#vv#v#v:V e405 5T5v55/ 44 eaef4yt$ $$Ife!vh#v #vT#vv#v#v:V e405 5T5v55/ 44 eaef4yt$ $$Ife!vh#v #vT#vv#v#v:V e405 5T5v55/ 44 eaef4yt$ $$Ife!vh#v #vT#vv#v#v:V e405 5T5v55/ 44 eaef4yt$ $$Ife!vh#v #vT#vv#v#v:V e405 5T5v55/ 44 eaef4yt$ $$Ife!vh#v #vT#vv#v#v:V e405 5T5v55/ 44 eaef4yt$ DyK yK (http://www.nlsa.us)j 666666666vvvvvvvvv666666>6666666666666666666666666666666666666666666666666hH6666666666666666666666666666666666666666666666666666666666666666662 0@P`p2( 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p8XV~ OJPJQJ_HmH nH sH tH J`J Normal dCJ_HaJmH sH tH DA D Default Paragraph FontRi@R 0 Table Normal4 l4a (k ( 0No List 44 Pt0Header  H$6o6 Pt0 Header CharCJaJ4 4 Pt0Footer  H$6o!6 Pt0 Footer CharCJaJPK![Content_Types].xmlN0EH-J@%ǎǢ|ș$زULTB l,3;rØJB+$G]7O٭V$ !)O^rC$y@/yH*񄴽)޵߻UDb`}"qۋJחX^)I`nEp)liV[]1M<OP6r=zgbIguSebORD۫qu gZo~ٺlAplxpT0+[}`jzAV2Fi@qv֬5\|ʜ̭NleXdsjcs7f W+Ն7`g ȘJj|h(KD- dXiJ؇(x$( :;˹! I_TS 1?E??ZBΪmU/?~xY'y5g&΋/ɋ>GMGeD3Vq%'#q$8K)fw9:ĵ x}rxwr:\TZaG*y8IjbRc|XŻǿI u3KGnD1NIBs RuK>V.EL+M2#'fi ~V vl{u8zH *:(W☕ ~JTe\O*tHGHY}KNP*ݾ˦TѼ9/#A7qZ$*c?qUnwN%Oi4 =3N)cbJ uV4(Tn 7_?m-ٛ{UBwznʜ"Z xJZp; {/<P;,)''KQk5qpN8KGbe Sd̛\17 pa>SR! 3K4'+rzQ TTIIvt]Kc⫲K#v5+|D~O@%\w_nN[L9KqgVhn R!y+Un;*&/HrT >>\ t=.Tġ S; Z~!P9giCڧ!# B,;X=ۻ,I2UWV9$lk=Aj;{AP79|s*Y;̠[MCۿhf]o{oY=1kyVV5E8Vk+֜\80X4D)!!?*|fv u"xA@T_q64)kڬuV7 t '%;i9s9x,ڎ-45xd8?ǘd/Y|t &LILJ`& -Gt/PK! ѐ'theme/theme/_rels/themeManager.xml.relsM 0wooӺ&݈Э5 6?$Q ,.aic21h:qm@RN;d`o7gK(M&$R(.1r'JЊT8V"AȻHu}|$b{P8g/]QAsم(#L[PK-![Content_Types].xmlPK-!֧6 0_rels/.relsPK-!kytheme/theme/themeManager.xmlPK-!0C)theme/theme/theme1.xmlPK-! ѐ' theme/theme/_rels/themeManager.xml.relsPK] !6 'L  0b L l m  XL# @0(  B S  ?sVItVI ## 8*urn:schemas-microsoft-com:office:smarttagsCity9*urn:schemas-microsoft-com:office:smarttagsplace pO$ &0  IK 3((N[   N[L L ) B0^`0OJQJo(hH^`OJQJ^Jo(hHo^`OJQJo(hHpp^p`OJQJo(hH@ @ ^@ `OJQJ^Jo(hHo^`OJQJo(hH^`OJQJo(hH^`OJQJ^Jo(hHo^`OJQJo(hH) BHھE         N&f/54Ptdj A$ @**** @UnknownG* Times New Roman5Symbol3. * Arial?. Arial Black7.@ Calibri?= * Courier New;WingdingsA$BCambria Math"qh3o 4y3o 4y$20n n KQHP  $PPt2!xx Application form (00034347).DOC 00034347.DOC   Oh+'0$ 0< \ h t  Application form (00034347).DOC00034347.DOC DO NOT STAMP  Normal.dotm 2Microsoft Office Word@@n4C@@3o ՜.+,D՜.+,@x  [Compatibility Mode]y4n   Application form (00034347).DOC Title 8@ _PID_HLINKSAdDhttp://www.nlsa.us)/  !"#%&'()*+,-./012346789:;<>?@ABCDGRoot Entry FIData 1Table$!WordDocument46SummaryInformation(5DocumentSummaryInformation8=CompObjr  F Microsoft Word 97-2003 Document MSWordDocWord.Document.89q