Landlord-Tenant Contact Form

Name

Email Address

Phone Number

Business Phone

Cellular or Pager

Address

County

City

State

Zip

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

Business address

County

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

Have you used any other personal or business name(s) in the last six years?
Yes  No 

If yes, please list here

Who else can we call if we cannot reach you?

Contact's name

Contact's telephone numbers

Work

Home

What is the address of the rental property in question?

County

City

State

Zip

Are you presently living at this address?
Yes  No 

If not, what dates did you reside there

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)?

When you signed the lease or rental agreement were you working with a real estate agent or rental agency service?
Yes  No 

If yes, please provide the name and contact information of the person or company you were working with

Name

Address

Telephone number

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

Please describe the nature of the problem

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

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

What was the response of the landlord or property owner?

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

What was the response of the tenant?

Please provide the following financial information, if applicable

Monthly Expenses

Do you have other financial obligations?
Yes  No 

If yes, to whom and how much?

Estimate balances owed on all other types of debt

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