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Housing Justice Project-Tenant Request Form

Housing Help

Name*
First Middle Last
Birthdate*
MM
DD
YYYY
Phone*
Is it ok to text this number?
- Yes
- No
Email*
Enter Email Confirm Email
What is your preferred language?*
Gender*
Ethnicity*
Race*
Are there other adults in the home?*
- Yes
- No
If yes, please list how many and their names*
Number of people in your household under the age of 18*
Current monthly household income*
What county do you live in?*
- Douglas
- Chelan
- Other
What is the name of your county?*
What is your current address?
Describe your concerns/issues
Have you talked with an attorney about this issue?*
- Yes
- No
Have you talked to your landlord about your concerns? What did you say and when did you say it?
Landlord's Name*
First Last
How much is your monthly rent?*
Do you owe back rent?*
- Yes
- No
How much rent is due now?*
Did you sign a lease with your landlord?*
- Yes
- No
Please select all that are true:
- I still have a copy of the lease
- The lease is still valid
- I signed a lease but I don't have a copy
- The lease expired and I am now on a month to month lease
- Other
Please explain
Have you received any notices from your landlord?*
- Yes
- No
If you selected "yes" above, what types of notices were they?
Do you want help negotiating a payment plan with your landlord?
- Yes
- No
- Not sure
Upload any notices or images:
Drop files here or

Accepted file types: jpg, png, pdf, Max. file size: 256 MB, Max. files: 5.
Understanding*
I understand that completing this form does not guarantee service.

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