Name (*)

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Email Address (*)

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Phone Number

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Business Phone

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Cellular or Pager

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Address

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County

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City

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State

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Zip

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If you are representing a business or property owner, what is their name?

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Business address

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County

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What type of business is it? (sole proprietorship, LLC, etc.)

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Have you used any other personal or business name(s) in the last six years?
yes   no
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If yes, please list here

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Who else can we call if we cannot reach you?

Contact's name

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Contact's telephone numbers

Work

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Home

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What is the address of the rental property in question?

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County

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City

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State

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Zip

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Are you presently living at this address?
yes   no
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If not, what dates did you reside there

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When living there, which did you have - a lease agreement (generally agreements for six months to one year) or a rental agreement (generally month-to-month arrangements)?

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When you signed the lease or rental agreement were you working with a real estate agent or rental agency service?
yes   no
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If yes, please provide the name and contact information of the person or company you were working with

Name

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Address

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Telephone number

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What problem or issue are you having/were you having with your rental housing (check all that apply)?
discrimination
security deposit
maintenance
injury/illness
eviction
rent
unsafe dwelling
privacy
lease termination
other

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Please describe the nature of the problem

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On what dates did the problem(s) occur? Please be as specific as possible

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If you are a tenant, what contact have you had with the landlord or property owner regarding this matter? Include information on dates of and type of contact (i.e. telephone call, letter), if known

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What was the response of the landlord or property owner?

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If you are the landlord, what contact have you had with the tenant regarding this matter?

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What was the response of the tenant?

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Please provide the following financial information, if applicable

Monthly Expenses

Rent $

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Electric $

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Gas $

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Water $

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Phone $

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Cable $

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Trash $

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Real Estate Taxes $

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Home Maintenance $

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Life Insurance $

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Health Insurance $

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Auto Insurance $

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Property/Rent Ins.

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Real Estate Payment

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Do you have other financial obligations?
yes   no
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If yes, to whom and how much?

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Estimate balances owed on all other types of debt

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Special Concerns or Further Information

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