ࡱ> egd7 <bjbjUU "V7|7| l>>>>$$$8\<w,8@2"TTTr+t+t+t+t+t+t+$- /h+Qu|QQ+>>TT!1,Q>TTr+Qr+Fa6*h6r+T4 )$m*r+G,0w,*7070r+>>>>Questions in RED must be completed: SCREENER:  FORMDROPDOWN   FORMTEXT       DATE:  FORMTEXT  DATE \@ "M/d/yyyy" 7/13/20057/13/2005 CLIENT INFORMATION:  FORMTEXT        CLIENT NAME:  FORMTEXT       CLIENT ADDRESS:  FORMTEXT       PHONE:  FORMTEXT       COUNTY:  FORMCHECKBOX  Check if there is a conflict with this client.  FORMCHECKBOX  Check if Judicare has previously assisted Client in this matter.  FORMCHECKBOX  Check if Client has been in court before with this landlord.  FORMCHECKBOX  Check if Client is known by any other name.  FORMTEXT       Type other name: LANDLORD INFORMATION:   FORMTEXT       LANDLORD NAME:  FORMTEXT       LANDLORD ADDRESS:  FORMTEXT       LANDLORD PHONE:  FORMCHECKBOX  Check if landlord is the caller/client.  The attorney you talk with will NOT represent you. She will only provide advice. A. Please tell caller to have any paperwork, such as a lease or notices from the landlord, in hand when speaking to the Helpline Attorney. B. Does the client have any paperwork we need to see?  FORMTEXT       C. If yes, can the client fax us the paperwork?  FORMTEXT       PLEASE ASK THE CALLER THE FOLLOWING QUESTIONS:  FORMTEXT       How long have you been renting this apartment/mobile park lot?  FORMDROPDOWN  Are you still living in the apartment/mobile home? $ FORMTEXT       How much do you pay for rent?  FORMDROPDOWN  Did you sign a lease?  FORMTEXT       If yes, when did you sign the lease?  FORMDROPDOWN  Is your name on the lease?  FORMTEXT       Is there any other name on the lease?  FORMDROPDOWN  What is the term of your lease?  FORMDROPDOWN  If no lease, when do you pay rent?  FORMDROPDOWN  Is there a specific problem with the apartment? If OTHER, please explain:  FORMTEXT        FORMDROPDOWN  Did you know of any of these problems before you moved in?  FORMDROPDOWN  If NO, have you notified your landlord of the problems you are having with your apartment?  FORMDROPDOWN  If YES, how did you notify your landlord?  FORMDROPDOWN  Are you able to live in your apartment?  FORMDROPDOWN  Have you ever decided not to pay rent because of the condition of your apartment?  FORMDROPDOWN  Did you speak with an authority figure or city/county official about the problems you have with your apartment?  FORMDROPDOWN  Have you reported the landlord to the City Housing Inspector?  FORMTEXT       If YES, when did you make the report?  FORMDROPDOWN  How did you make your report?  FORMDROPDOWN  Has anyone responded to your complaint?  FORMDROPDOWN  Does your apartment need any repairs? If YES, explain what needs to be repaired:  FORMTEXT       What caused the damage that needs the repair?  FORMTEXT        FORMDROPDOWN  10. Has your apartment been repaired in the past?  FORMTEXT       If YES, explain the repairs made:  FORMDROPDOWN  11. Do you owe any rent on the apartment?  FORMDROPDOWN  Have your personal belongings been damaged? If YES, explain the damage:  FORMTEXT       Is there any additional information the Helpline Attorney should know about your apartment, landlord, or repairs issue?  FORMTEXT       AFTER YOU HANG UP WITH THE CLIENT, PLEASE FILL IN THIS SECTION: In 2-3 sentences, briefly summarize the NATURE of the caller s complaint: (What is the client s legal problem)?  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