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)



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