LAS Priorities Survey - Client Please take a few minutes to answer some questions about legal problems you might have. This survey will help Legal Aid decide what kinds of cases to take. For some questions you may choose more than one answer. Thank you for your help. OK Question Title * 1. What Tennessee county do you live in? Anderson Bedford Campbell Cannon Cheatham Claiborne Clay Coffee Cumberland Davidson DeKalb Dickson Fentress Franklin Giles Grundy Hickman Houston Humphreys Jackson Lawrence Lewis Lincoln Macon Marshall Maury Montgomery Moore Morgan Overton Perry Pickett Putnam Roane Robertson Rutherford Scott Smith Stewart Sumner Trousdale Union Van Buren Warren Wayne White Williamson Wilson Other (please write below) OK Question Title * 2. Please check all that apply. I am age 60 or older I am a veteran. I have someone in my home who does not speak English well. I am disabled. I have children under 18 in my home. I came to the U.S. from another county. I need a job. I have people over age 60 in my home. I am retired. My income is low. I have gotten help from Legal Aid. Other (please write below) OK Question Title * 3. Please check one. I own my own home. I live in public or Section 8 housing. I live in a place where I pay the whole rent. I live with others and pay my own way. I live with others and do not pay rent and/or my own way. I am homeless. I pay rent OK Question Title * 4. During the past year has anyone in your household had legal problems with (OK to check more than one) Getting a doctor's services? TennCare? Getting or paying for medicine? Private health insurance? Paying medical bills? Getting home health care? Getting hospital services? Getting nursing home care? Medicare? Getting mental health services? Other health problem? (please write below) OK Question Title * 5. During the past year has anyone in your household had legal problems with (OK to check more than one) Juvenile court? Grandparents' rights? Divorce Guardianship of a child or conservatorship for an adult who can't make decisions for themself? Child custody or visitation? Getting a divorce or separation? Family violence / spouse abuse / other abuse my someone you know? Adoption? Name change? Getting child support? Other family problem? (please write below) OK Question Title * 6. During the past year has anyone in your household had legal problems with (OK to check more than one) Bankruptcy? Something wrong on your credit report? Getting credit? Check advance or title loan company? Bills you can't pay? Bill collectors? Collecting money owed to you? Identity theft? Getting ripped off? Unfair credit? Other money problem? (please write below) OK Question Title * 7. During the past year has anyone in your household had legal problems with (OK to check more than one) Foreclosure? Being evicted or locked out without going to court? Public or Section 8 housing? Private landlord? Unfair credit? Making mortgage payments? Unsafe or unhealthy rental property? Having utilities cut off by landlord? Other housing problem? (please write below) OK Question Title * 8. During the past year has anyone in your household had legal problems with (OK to check more than one) SNAP or Food Stamps? Veterans' benefits? Income tax Unemployment benefits? Wage claims Workers' Comp? Supplemental Security Income (SSI)? Social Security Retirement benefits? Social Security Disability benefits (SSDI)? Other public benefits problem? (please write below) OK Question Title * 9. During the past year has anyone in your household had legal problems with (OK to check more than one) Wills? Driver's or other license? Income taxes? School discipline? Paying public school fees for supplies or field trips? Court costs? Special education? Cleaning up criminal record? Immigration? Any other problem not listed? (please write below) OK DONE