ࡱ> gif7 bjbjUU "Z7|7|+l8888pD*\T"vvv %)))))))$+ -|)|)vv!}*vv))L r(T@)vP ]PX8))*0*)U.U.)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 NUMBER:  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        FORMDROPDOWN  PLEASE ASK THE CALLER THE FOLLOWING QUESTIONS: Which utility are you calling about?  FORMDROPDOWN  Who is the company providing the utility in question?  FORMDROPDOWN  Is the Utility Company suing you?  FORMDROPDOWN  If YES, what is the suit for?  FORMDROPDOWN  Did you receive a disconnect notice?  FORMTEXT       If YES, WHEN did you get the notice?  FORMTEXT       If YES, on what date will the service be shut off?  FORMDROPDOWN  If YES, WHY did you get the notice?  FORMDROPDOWN  Has your utility been shut off? If NO, state your concern with the Utility Company:  FORMDROPDOWN  If OTHER please explain:  FORMTEXT        FORMDROPDOWN  Did you live in the home or the apartment when the utility service was used?  FORMDROPDOWN  Do you normally pay the utility bill?  FORMTEXT       If NO, who pays the bill?  FORMDROPDOWN  Do you receive any form of energy or utility assistance payments? If YES, what form of energy assistance have you received, and when it was received:  FORMTEXT        FORMDROPDOWN  Did you get behind in your payment on your utility? If YES, why did you get behind?  FORMTEXT        FORMDROPDOWN  Do you have a payment arrangement with the utility company? What is your arrangement?  FORMTEXT        FORMDROPDOWN  Have you tried to make payment arrangements with the utility company? If YES, what was the response of the utility company?  FORMTEXT        FORMDROPDOWN  Is there anyone in the home with a medical problem that a utility shutoff would affect? If YES, List the names and ages of the persons the utility shut off would affect (if that person is other than you.)  FORMTEXT        FORMDROPDOWN  Do you rent or own your dwelling?  FORMDROPDOWN  Is anyone else using your utilities?  FORMTEXT       If YES, state who:  FORMDROPDOWN  Have you had any discussions with the utility company? If YES, what was the topic of these discussions?  FORMTEXT        FORMTEXT       Is there any additional information the Helpline Attorney should know about your apartment, landlord, utility company, etc.? 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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