Offices located in the New York Tri-State Area
Toll Free: 1-877-Stork-Law or 1-877-786-7552
Phone: (914) 738-0492 | Fax: (914) 738-5654
Info@StorkLawyer.com

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Printable Application

In order for our office to fully evaluate your financial situation please send the following information typewritten (no handwritten submissions will be accepted) together with the supporting documentation requested, by regular mail. All documents must be received together by the deadline for submission:

  1. The Type of Legal Services Scholarship for which you wish to apply for (e.g., Free Legal Services for an Egg Donation Agreement).
  2. The full legal names and addresses and contact information for each applicant for the Free Contract (if married or in a partnership, each individual must provide complete information).
  3. The Social Security Number for each applicant.
  4. Your most recent Federal and State Tax return, for each applicant unless filed jointly.
  5. A brief description of each applicant’s employment status, including the name of your employer (if applicable), your job title or position, your income (annual, hourly, overtime and bonus information if applicable) and any other information relative to your employment status you wish to have considered as part of your application. A copy of your most recent pay stub may be requested.
  6. A list of the sources of any additional income you may have (family support, first or second mortgage, home equity loan or line of credit, available balances on credit cards).
  7. A description of any additional expenses you may have that you wish to have considered as part of your application (for example, child support payments).
  8. Any information concerning insurance coverage that may be available to help pay for your medical treatment, including any documentation from your insurance carrier that you don’t have coverage for infertility treatment, you have reached the maximum allowable benefit or have a limit on the remaining amount available of insurance coverage available.
  9. An essay describing the history of your infertility and efforts to have a baby including but not limited to your infertility diagnos(es), types of treatment attempted to date (and the success if any of such treatment), the amount of money you have spent out-of-pocket on treatment and any monies or assistance your family or friends have provided to you, a description of what attracted you to egg donation and/or gestational surrogacy and how many attempts you’ve made to date to either locate a donor or surrogate or to work with a donor or surrogate, information concerning the agency you’re working with (or your work independently to locate an egg donor or surrogate), and any other information you feel might help us evaluate your financial situation and/or your commitment to building your family through third-party assisted reproduction.
  10. Your anticipated cycle start date, if you have one. The name of any egg donation or surrogacy agency (or attorney) with whom you are currently working or have worked in the past and any information concerning their fees and refund policies you wish us to consider as part of your application.
  11. A written release authorizing the law office of Elizabeth Swire Falker, Esq. P.C. to perform a credit check to verify information submitted in connection with your application. A release for will be forwarded to you upon receipt of your application.
  12. A return self-addressed stamped envelope in which to return all documents to you.
  13. All information submitted to the Law Office of Elizabeth Swire Falker, Esq., P.C. will be maintained in the strictest of confidence. Upon conclusion of our review, all documents submitted will be returned to the applicant in the SASE provided with the application unless other arrangements are requested in advance.

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