Contra Costa Tenant COVID-19 Form
Are you a renter in Contra Costa County unable to pay rent due to COVID-19? Fill out this form below to share your story and get connected. ¿Eres inquilino en el Condado de Contra Costa y no puedes pagar el alquiler debido a COVID-19? Completa esta forma para conectarse.
* Required
Tenant Name/Nombre
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Your answer
Organizer Name:
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Your answer
If tenant is calling organizer about the clinic, where did they hear about us?
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Your answer
E-mail Address / Correo Electronico
Your answer
Phone Number / Numero de telefono
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Your answer
Address (Number, Street Name, City) / Dirección (Numero, Calle, Ciudad)
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Your answer
Property Owner Name / Management Name / Nombre del Propietario / Nombre de la Administración *
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Your answer
What is your monthly rent? / ¿Cuánto es su renta mensual? *
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Your answer
Occupation / Ocupación
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Your answer
Primary language / Idioma principal *
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Your answer
Have you been unable to pay rent due to reasons related to COVID-19? / ¿No ha podido pagar la renta por razones relacionadas con COVID-19?
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Yes / Si
No
How have you been impacted by COVID-19? / ¿Cómo ha sido impactado por COVID-19?
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Loss of job/income / Pérdida de trabajo / ingresos
Increase in out-of-pocket medical expenses / Aumento de gastos médicos
Reduction of work hours / Reducción de horas de trabajo
Layoff or furlough / Despido de trabajo
Need to miss work to take care of school-age child / Necesidad de faltar al trabajo para cuidar a un niño de edad escolar
Other:
Required
Has your landlord responded in any of the following ways after stating your inability to pay rent due to COVID-19? / ¿Ha respondido su propietario de alguna de las siguientes maneras después de indicar su incapacidad de pagar la renta debido a COVID-19?
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Rent increase / Aumento de renta
Eviction notice / Noticia de desalojo
Harassment/threats / Acoso / amenazas
Lock-out
Forcing you to sign payment plan (REMEMBER: the law does NOT require you to sign a plan!) / Obligarle a firmar un plan de pago (RECUERDE: ¡la ley NO requiere que firme nada!)
Other:
Required
If you are dealing with harassment by your landlord, please detail type of harassment here.
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Your answer
How has COVID-19 affected you and your family? Share your story. / ¿Cómo le ha afectado COVID-19 a usted y a su familia? Comparte su historia.
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Your answer
You are not alone! Many renters across the U.S. are struggling during this time. Now is the time to make our voices heard to fight for a safe and secure future.
No estas solo! Muchos inquilinos están sufriendo durante este tiempo. Ahora es el momento de hacer que nuestras voces sean escuchadas para luchar por un futuro seguro y estable.
Do you consent to having community organizations share your story on social media and to local and state politicians? / ¿Las organizaciones comunitarias podrian compartir su historia en las redes sociales y con los políticos locales y estatales?
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Yes / Si
Yes, anonymously / Si, anónimamente
Maybe / Tal vez
No
Are you interested in learning more about how to get involved in tenant rights organizing? / ¿Está interesado en aprender más sobre cómo participar organizer para para los derechos de los inquilinos?
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Yes / Si
Maybe / Tal vez
No
Thank you! Gracias! For more information / Para mas informacion: www.linktr.ee/raisetheroofconcord and www.linktr.ee/todossantostu
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