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.

Congress of Neutrals – 1390 Willow Pass Road, Suite 190, Concord CA, 94520