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