Pre-Screening Form for Free Eviction Prevention Legal Clinic

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Fill out this form to see if you qualify to get free legal advice about eviction from an attorney at the City of Albuquerque clinic on May 25th, 2022. The information you provide will only be used to see if you qualify for this clinic and will not be shared or used in any other way. A city representative will contact you for more information after you submit this form.

Email *

Preferred Language *

Your full legal name including all middle names and last names *

Date of Birth DD/MM/YY *

YYYY

Who is your landlord?

Your Street Address *

City/County *

State *

Zip code *

Phone number *

Gender Identification *

Female

Male

Non binary

Prefer not to say

Race *

American Indian/ Alaskan Native Alone (North Central and South American)

African American Alone

Asian Alone

Native Hawaiian/ Pacific Islander Alone

two or more

White Alone

Other...

Ethnicity *

Hispanic / Latino

Not Hispanic Latino

Immigration Status *

U.S Citizen

Legal Permanent Resident (also known as green card holder)

Other lawful status with an employment authorization document ("EAD" also known as a "Work Permit"

No status

Household Income *

Less than $10,000 a year

Between $10,000 to $20,000 a year

Between $20,000 to $34,999 a year

Between $35,000 to $49,999 a year

Between $50,000 to $74,999 a year

Between $75,000 to $99,999 a year

Over $100,000 a year

Number of people in household *

Disability Status *

I have a registered disability

I have an unregistered disability

I don't have a disability

Veteran Status *

Veteran

I am not a veteran

Education Level *

Less than High School

High School Diploma/ GED / Equivalent

Some College/ Associates/ Trade School

Trade certification

Bachelors degree

Post graduate degree

Have you applied for Emergency Rental Assistance (ERAP) ? *

Yes, I recently applied and am waiting for a response

Yes I applied before and got rent help (less than 3 months ago)

Yes I applied before and got rent help (more than 3 months ago)

I applied but was denied

No, I have never applied

I don't know how to apply

I need help on submitting my application

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