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Name*

First Last

Date of Birth*

Language You're Most Comfortable Speaking In*

Are you a veteran of the U.S. military?*

Yes

No

Phone Number*

Email

Address*

Street Address Address Line 2 City State ZIP Code

How many years have you lived in your apartment?*

What is your monthly rent?*

Approximately how many apartments are in your building?*

Housing Type*

Rent-regulated

Market-rate

Gov’t-assisted

Housing Subsidy Type (if you receive a housing subsidy, click one or more of the following)

HRA Subsidy (FEPS, CityFEPS, SEPS, FHEPS, etc.)

Section 8

SCRIE/DRIE

ACS Subsidy

Are you currently in housing court?*

Yes

No

What is the index number or docket number for your case?*

The index or docket number can be found on the top right corner of the court papers, it begins with LT-

Number of Adults (18+ years old), including yourself*

Number of Children (under 18 years old)*

Number of Seniors (60+ years old), including yourself*

Gross Monthly Income of All Adults in Your Apartment*

Amount from wages

Amount from unemployment insurance

Amount from pension

Amount from SSD/SSR/SSI

Amount from other sources

Do you or does anyone else receive Public Assistance or Food Stamps (SNAP)?*

Yes

No

Have you ever applied for Public Assistance or Food Stamps?*

Yes

No

Your Public Assistance #*

Amount of Monthly Cash Assistance*

Amount of Monthly Shelter Allowance*

Amount of Monthly Food Stamps*

Have you ever received a "one-shot deal" from HRA?*

Yes

No

(One-Shot Deal = payment by HRA to the landlord for rent you owe when an eviction case is brought against you)

When did you receive the one-shot deal? (month & year)*

Brief Summary of Housing Issue*

Here are a few things to consider when providing a summary of your housing issue:
- Can you briefly describe the issue you are facing with your housing?
- What is the main concern or problem you're trying to address with your housing situation?
- What actions have you already taken to try and resolve the issue on your own?
- What is the outcome you hope to achieve by reaching out for legal assistance?
- Are there any immediate deadlines or urgent concerns we should be aware of related to this issue?
- Is there anything specific you would like advice or assistance with regarding your housing situation?

Digital Signature*

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First Last

Date*

Intake Form