Name*

First Last

Address*

Street Address Address Line 2 City State ZIP Code

Phone*

Email*

Enter Email Confirm Email

Certification 1*

I certify that:

The information provided in this application and the Financial Statement submitted as part of the application is true and correct to the best of my knowledge.

Certification 2*

I certify that:

The CDI Modest Means Program may verify the accuracy of the information provided about the applicants' household, assets, and income and that the case may be closed at any time upon learning that the information provided is incorrect.

Certification 3*

I certify that:

If an attorney accepts the applicant's case, the relationship between the applicant and applicant's attorney will be governed by the agreement between the applicant and the applicant's attorney.

Certification 4*

I certify that:

Any attorney, law office staff, or other professional or agency to which this matter is referred by the CDI Modest Means Program has permission to respond by phone or in writing to requests made by the CDI Modest Means Program for information about the applicant's case.

Certification 5*

I certify that:

I agree to abide by the principles of the Collaborative Law Process.

Certification 6*

I certify that:

I understand that the CDI Modest Means Program does not guarantee that it will find an attorney who will accept the applicant's case.

Certification 7*

I certify that:

I understand that if the CDI Modest Means Program refers me to an attorney who has offered to participate in providing Modest Means Collaborative Divorce services, the attorney may refuse to accept the applicant's case if it is deemed to not be appropriate for the Collaborative Process, would involve violation of law or Rules of Professionals Responsibility, or other legitimate reasons.

Certification 8*

I certify that:

I release Collaborative Divorce Illinois and its officers, directors and agents from any and all claims, losses, and liability arising out of any referral made by or through the Collaborative Institute of Illinois Modest Means Program.

Certification 9*

I certify that:

I understand that failure to comply with schedules and appointments made with Modest Means Program Collaborative Professionals will mean immediate dismissal of my case.

Certification 10*

I certify that:

I authorize Collaborative Divorce Illinois Modest Means Collaborative Divorce Program to disclose specific intake information about the applicant and his/her family to the participating professionals involved in the Modest Means Program for the purpose of screening the applicant's case for participation in the Modest Means Program, and referring the applicant's divorce case to a Modest Means Program professional team if it is determined that the applicant's case is appropriate.

Certification 11*

I certify that:

I agree to cooperate with the Modest Means Program after the referral is made, and further understand that Collaborative Divorce Illinois Modest Means Program will protect the confidentiality of the information I have given as required by law, and if the applicant abandons the process, Collaborative Divorce Illinois Modest Means Program will destroy the information except for the retention of contact information to administer the applicant's case.

Spouse's Name*

First Last

Signature - Enter your full name to certify and submit your application.*

Date*

MM slash DD slash YYYY

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Modest Means - Spouse Application and Certification Form