The document is a legal services request/report form from the Georgia Department of Human Resources. It requests information about a DFCS client case including the client and child names, county, program area, eligibility status, and reasons for legal consultation or representation. The form also requests a list of all legal activity on the case for the month submitted, including dates, activities, and time involved. It provides instructions to prepare the form in triplicate and route copies to the appropriate program director by the 10th of each month.