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  Trial Defense Service
  Intake Form
 This system is being beta tested by the states of Wisconsin, Michigan, Illinois Indiana, and Ohio. If you are in another state, please contact your Staff Judge Advocates office for number to call for representation.
 Client Information
 Rank and Name RankFirst Name*Last Name*
 Address Street*Street 2City*State*(None)AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyomingZip*
 State in Which You're a Member* (None)AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming
 Phone Number*
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 Age*
 Marital Status* SingleMarriedSeparatedDivorcedWidowed
 Current Legal Issue
 Could this involve sexual harassment or sexual assault allegations?* Yes   No
 Please describe your current legal issue*
 Do you currently have an attorney? Yes   No
 Attorney's Name
 Attorney's Phone
 Attorney's Email
 Military Information
 Status* Title 10 Active DutyTitle 32 Full-Time National Guard DutyState Active DutyActive Guard Reserve (AGR)M-Day(N/A)
 Time in Service
 Expiration Term of Service (ETS)
 Deployments Please list locations and dates.
 College/Higher Education
 Current Status Graduated   Currently Enrolled   Planning   N/A
 Using Military Benefits for School Yes   No   N/A
 Prior Legal Issues
 Do you have prior legal issues? Yes   No
 Please describe your prior military issues
 Did you have an attorney? Yes   No
 Attorney's Name
 Attorney's Phone
 Attorney's Email
 Please describe your prior civilian issues
 Did you have an attorney? Yes   No
 Attorney's Name
 Attorney's Phone
 Attorney's Email
 Medical History
 Have you deployed within the last 24 months? Yes   No
 Do you currently have a medical condition? Yes   No
 Are you currently in the Medical Board Process? Yes   No
 Do you have a VA Rating? Yes   No
 Are you currently on a Profile? Temporary   Permanent   Both Temporary and Permanent   No
 Unit Information
 Unit Name
 Unit PoC Rank & NameUnit PoC Phone NumberUnit PoC Email Address
 Unit Duty PositionUnit CityUnit State(None)AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming
 Primary MOS
 USE OF THIS TDS CONTACT FORM DOES NOT ESTABLISH AN ATTORNEY‐CLIENT RELATIONSHIP. You will receive further information from TDS about your assigned defense counsel and next steps. You agree that assigned defense counsel may contact you first by any means of communication you specify in this form without such contact being a “solicitation” under any State or Territorial rules of professional conduct for lawyers.
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