UNLAWFUL DETAINER MEDIATION INTAKE FORM – TENANTS
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: _____________________
Your Name: __________________________________________
Best Contact Phone Number: _____________________________
Email: ________________________________________
Is there a lease: _____________________
Type of Lease: ____________Monthly ___________Yearly___________ Other
Monthly Rent:____________________________
Rent Due Date: _____________________________
Have you missed any rent payments: _____________________
When was the last rent payment made: ________________________
Total amount of unpaid rent:________________________________
Has Covid-19 (Corona virus) impacted your work?___________________
Are you still receiving your full paycheck? _________________________
Other than your paycheck, do you receive income from any other source? __________________
Once the lockdown is lifted, do you expect to go back to receiving your full paycheck from your employer?
________________
If no, do you have any other employment options_________________________
Do you wish to continue to live at this property? _________________
If no, when are you planning on moving? ____________________________
If yes, Do you have a plan in mind to pay the rent? Explain
______________________________________________________________________________
Do you have any savings, or other accounts that you can withdraw upon to pay the rent? (if you do not wish to
write it down, but would rather discuss it with the Mediator, please leave it blank)
_____________________________________________________________________________
_____________________________________________________________________________