Client Eviction Intake Form
Today’s Date:
/
Month
/
Day
Year
Date
Referral Source:
Google
Internet
Friend
Telephone
Other
Area of Law:
1. CLIENT
Name:
Address:
City:
State:
Zip:
Mailing Address (if different):
Email Address:
example@example.com
Home Phone:
Cell Phone:
Date of Birth:
/
Month
/
Day
Year
Date
Soc. Sec. No.:
Nearest Relative:
Relationship:
Address of nearest relative:
Phone of nearest relative:
County resided in last 90 days:
State resided in last 6 months:
2 CLIENT EMPLOYMENT INFORMATION
Employer Name:
Employer Phone:
Spouse Employer:
Spouse Employer Phone:
3. TENANT' S PERSONAL INFORMATION
Name:
Address:
City:
State:
Zip:
Phone:
4. TENANT' S EMPLOYMENT INFORMATION
Employer Name:
Employer Address:
City:
State:
Zip:
Employer Phone:
5 CASE INFORMATION
Date of Lease:
/
Month
/
Day
Year
Date
Amount of Rent Due each month:
Date last paid rent:
/
Month
/
Day
Year
Date
Amount paid:
Total amount past due:
Additional Comments:
Preview PDF
Submit
Should be Empty: