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