Fill and Sign the Tenants Form

Eviction Questionnaire for Tenants Name:       Current Address (street #) (apt. #) (zip code) :       Phone: (h)       (w)       (cell)       Address where wrongful eviction occurred:       Did anyone else live in the apartment? Yes No If yes: Adults:       Children (with dates of birth) :       D ate you moved in:       Current rent:       Security Deposit:       Number of bedrooms:       Total rooms:       Do you have a written rental agreement or lease? Yes No (if yes, please attach) Name of landlord:       Landlord’s attorney:       Telephone: Landlord:       Landlord’s attorney:       Management company, if any:       Does landlord live in building? Yes No Is there a resident manager in the building? Yes No If yes, name:       Date you received first eviction notice of any type (verbal or written from landlord):       Any other notices? Yes No If yes, describes notice, with date and whether written or oral:       Date you moved from your home:       Describe sequence of events in as much detail, with dates, witnesses etc, as possible:       Describe all types of harm caused by this eviction: Type of harm Date Amount Evidence (witnesses, receipts, etc.                                                                                                                         Did you have repair problems? Yes No If yes, describe:       : If yes, what problems have you notified the landlord or management about:       Were any complaints in writing? Yes No Do you have copies of any letters you wrote? Yes No (if yes, please attach) Has the landlord or his/her employees done anything to harass you? Yes No First time in arrears? Yes No (if no, how often?):       Do you owe utilities?: Yes No Electric amount owed:       Gas amount owed:       Water/sewer amount owed:       Phone amount owed:       How will you pay your rent after being helped?       What were you told was the reason for eviction?       Do you know of others who have been evicted? Yes No If yes, please list: NAME HOME TELEPHONE NUMBER WORK TELEPHONE NUMBER                                                                         List the names and telephone numbers (if possible) of witnesses you feel could provide evidence in your support: NAME HOME TELEPHONE NUMBER WORK TELEPHONE NUMBER                                                                         List the names of individuals who obtained the housing you sought, if known: NAME HOME TELEPHONE NUMBER WORK TELEPHONE NUMBER                                                                         Have you filed a complaint with: United States Department of Housing? Yes No If yes, give name of contact person, address, phone number, and what person has done for you on this problem:       And urban development agency? Yes No If yes, give name of contact person, address, phone number, and what person has done for you on this problem:       Any other agency or group? Yes No If yes, give name of contact person, address, phone number, and what person has done for you on this problem:       Is the landlord holding any of your property? Yes No If yes, describe