MEDIATION SERVICES INTAKE FORM: TENANT
Email address *
TENANT INFORMATION
First Name *
Last Name *
Street Address, Line 1 *
Street Address, Line 2
City *
Zip Code *
Primary Phone Number *
This Phone Is: *
Alternate Phone Number
This Phone Is:
Clear selection
DEMOGRAPHIC INFORMATION
Our agency receives federal funding that requires us to obtain the following information. This information is collected for statistical reasons only and is kept in strict confidence. Please help us by filling in the information on this form. If you have any questions, our staff will be glad to help you.
Gender *
Age Range *
ETHNICITY *
RACE (Check all that apply.) *
Required
Including you, what is your family size? (Members in your household) *
Household Characteristics (Check all that apply.) *
Required
INCOME
The majority of funding for this mediation program serves individuals making 80% of Area Median Income or less. The chart below shows the current HUD income brackets for Allegheny County.
What is your ANNUAL Family Gross Income? Income includes any amount paid to you and your spouse/domestic partner through: work, dividends, child support, assistance programs like SSI/SSDI and TANF, etc. You may be asked for verification of income. *
Please use numbers only. Do not use a $ sign or comma.
Finding your Family Size and Family Gross Income on the chart above, which category describes your income? *
If your family size is more than 8 (including you), how many members are in your household?
If your family size is more than 8, what is your gross annual family income?
Please use numbers only. Do not use a $ sign or comma.
CERTIFICATION
I certify that the information I have provided on this form is true and accurate to the best of my knowledge, and I understand that the information provided here is subject to verification by HUD. By checking this box and typing my name below, I am electronically signing this certification. *
Required
Enter Full Name *
Today's Date *
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MEDIATION LOGISTICS
Mediation will be arranged for a single, three-hour session after a preliminary phone call.
Do you have the INTERNET ACCESS, WEBCAM capability, and PRIVACY necessary to participate in a mediation by videoconference? *
Do you have any physical, language, or other accessibility needs to be able to participate in mediation?
NATURE OF DISPUTE
Dispute Resolution Issues (Please check all that apply.) *
Required
If non-payment of rent is an issue in this case, would you benefit from rental assistance from an outside service provider to help pay back the balance owed?
Clear selection
Please give additional details about the nature and background of the dispute. Describe any agreements or referrals.
LANDLORD/PROPERTY MANAGER INFORMATION
Landlord/Property Manager First Name *
Landlord/Property Manager Last Name *
Property Name (if applicable)
Landlord/Property Manager Phone Number *
Landlord/Property Manager Alternate Phone Number (if known)
Landlord/Property Manager Email Address (if known)
Is the landlord/property manager aware of and interested in mediation? *
Will the landlord/property manager be the other party in the mediation? *
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