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Conjugal and sexual violence

I NEED A LAWYER

MAKE A
REQUEST

Individual
NPO

Formulaire SJ-Individus

Personal Information
The information provided in this form will be treated as confidential.
PLEASE READ THE FOLLOWING
BEFORE FILLING OUT A FORM
Our team considers that for domestic violence and post-separation cases it is essential that you be informed, advised or represented by a lawyer trained to face the complexity of these situations. Do not fill out the form below and click here to access our specialized team page.

Professional artists and cultural workers can click here for free legal services.

If your request involves violence or harassment in the workplace, click here for free legal services.

Consult our FAQ here before completing your application.

Email*

Enter Email Confirm Email

First name*

Last name*

Pronoun

Which Pronoun(s) do you wish to be addressed by

Date of Birth*

Civil status*

Address*

Residential Address*

Mailing Address Address Line 2 City Province / Territory Postal Code / Zip Code Country

Contact Information

Phone

Cell

Children and/or dependents

Number of children and/or dependents* (if applicable)*

What is the age of the children and/or dependents?

Income

What is your gross annual income? (before taxes) *

For decimal numbers, please use a decimal point (.) and not a comma.

Are you currently a salaried employee?*

Yes
No

Attach your complete federal and provincial Notices of Assessment

Drop files here or

Accepted file types: pdf, Max. file size: 128 MB, Max. files: 4.

Attach your federal and provincial income tax returns

Drop files here or

Accepted file types: pdf, Max. file size: 2 MB, Max. files: 4.

Upload files here or select files

Please attach your income tax returns so we can properly assess your eligibility

What is your current spouse's gross annual income (before taxes)?

For decimal numbers, please use a decimal point (.) and not a comma.

Do you receive child support? *

Yes
No

Indicate the amount per month of child support. *

Do you pay child support? *

Yes
No

Indicate the amount per month of child support.

Residence

Do you rent or own your home?*

Tenant
Owner

If you own your home, indicate its equity.

For decimal numbers, please use a decimal point (.) and not a comma.

Juripop and you

What is the preferred way to reach you?

May we leave you a message?

Yes
No

How did you hear about Juripop?

Indicate your legal aid status. *

Your case

What do you need? *

Is your case already before a court or tribunal?*

Yes
No

Please state the name of the court or tribunal

What is the next court date ?

Name of the opposing party *

Person or business with opposing interest

Name of all other parties involved in the litigation

If you received a formal letter, what is the deadline to respond?

Have you approached any other agencies for assistance?*

Yes
No

Which ones?

Are you a member of a union or other advocacy organization?*

Yes
No

Which ones?

Do you have legal insurance?*

Yes
No

Please explain your situation in less than 150 words.**

ACCEPTANCE OF THE COMPLIANCE OF THE INFORMATION SUBMITTED*

Attestation of the submitted information*

I guarantee that the information contained in this application is true and complete, to the best of my knowledge. I waive my right to hold Juripop, its employees, collaborators and volunteers responsible for any facts arising from this application. I authorize Juripop to: 1. provide this application and accompanying documents to its employees, collaborators and volunteers; 2. retain this application and accompanying documents. In order to send us your application, you must now proceed with the payment of the Juripop membership fee. If you have any questions, please refer to the section "Apply online - FEES".

Membership fees

Price: $ 20.00 CAD

The next step will be to complete the payment process for your membership. After pressing the submit button, you will be directed to the secure payment process.

I certify that membership to Juripop is NON-refundable.*

I understand that the membership to Juripop is NON-refundable.

Individual Member - Annual *

Price:

Method of payment*

Juripop Membership Number

If you are currently an active Juripop Member, please insert your Membership Number

the billing address is the same as the home address*

Yes
No

Residential Address*

Mailing Address Address Line 2 City Province / Territory Postal Code / Zip Code Country

In order for your request to be analyzed and your membership to be active, please issue a check and send it to Juripop :

Juripop 2006, rue Plessis Bureau 300 Montréal (Québec) H2L 2Y3

Please be sure to include: "Individual Membership" and your full name if your check is different from the person applying.

In order for your request to be analyzed and your membership to be active, please issue an interac transfer and send it to Juripop :

comptabilite@juripop.org

Please make sure to indicate: "Individual member membership" in the message. For the security question, please indicate: ADHESION2021

Credit Card

Card Details

Cardholder Name

TELEPHONE
1-855-JURIPOP 1-855-587-4767
FAX
450-845-1667
EMAIL
info@juripop.org
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