UNLAWFUL DETAINER MEDIATION INTAKE FORM – LANDLORDS
Please print and fill out the form below. When you are done, either return it by mail at the address below or scan your completed form and email it to chels15woodger@gmail.com.
What is easier for you: Telephone: ______________ Zoom: _____________________
Name of Landlord: _____________________________________
Best Contact Phone Number: _____________________________
Email: _______________________________________________
Property Manager/Agent (if applicable): _________________________________
Property Address: ____________________________________________________
Name of Tenant (please list all tenants for this property):
______________________________________________________________________________
______________________________________________________________________________
Best Contact Phone Number for Tenant: ___________________________________________
Email for tenant: __________________________________________
Is there a lease: _____________________
Type of Lease: ____________Monthly ___________Yearly___________ Other
Monthly Rent:______________________________
Rent Due Date: _____________________________
Has the tenant failed to pay rent: _____________________
When was the last rent payment made: ________________________
Total amount of unpaid rent:________________________________
Has an Unlawful Detainer Action Filed? ______________________
Has a 3 Day-Notice to Quit or Pay Rent Served: __________ If yes, When: ________________
Are you willing to work with the tenant to create a payment plan for the back rent? _______________
Do you have any other plan in mind to work with the tenant?* If so, please explain:
____________________________________________________________________________________
*If you do not wish to write it down but would rather discuss it with the Mediator, please leave this section blank.