Housing Justice Project-Tenant Request Form

Name*

First Middle Last

Birthdate*

MM

DD

YYYY

Phone*

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?*

Have you been unable to pay rent due to loss of wages because of COVID-19?*

Yes
No

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.

Housing Help