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 have someone in my home who does not speak English well. I am disabled. I have children under 18 in my home. I am a veteran. I have gotten help from Legal Aid. My income is low. I have people over age 60 in my home. I am age 60 or older I came to the U.S. from another county. I need a job. I am retired. 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) Medicare? Getting nursing home care? Getting a doctor's services? Private health insurance? Paying medical bills? Getting home health care? Getting mental health services? Getting hospital services? TennCare? Getting or paying for medicine? 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) Family violence / spouse abuse / other abuse my someone you know? Adoption? Name change? Getting a divorce or separation? Juvenile court? Divorce Getting child support? Guardianship of a child or conservatorship for an adult who can't make decisions for themself? Grandparents' rights? Child custody or visitation? 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) Identity theft? Something wrong on your credit report? Bills you can't pay? Bankruptcy? Getting ripped off? Bill collectors? Check advance or title loan company? Unfair credit? Collecting money owed to you? Getting 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) Public or Section 8 housing? Having utilities cut off by landlord? Unfair credit? Making mortgage payments? Private landlord? Being evicted or locked out without going to court? Foreclosure? Unsafe or unhealthy rental property? 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) Unemployment benefits? Social Security Retirement benefits? Wage claims Income tax Social Security Disability benefits (SSDI)? SNAP or Food Stamps? Veterans' benefits? Supplemental Security Income (SSI)? Workers' Comp? 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) Special education? Paying public school fees for supplies or field trips? Immigration? Driver's or other license? Cleaning up criminal record? School discipline? Income taxes? Court costs? Wills? Any other problem not listed? (please write below) OK DONE