EPM Pre-Mediation Assessment

I am a*

TenantLandlordProperty Manager

Full Name*

First NameLast Name

Primary Contact Number*

Primary Email Address*

Address

Address Line 2

CityState / Province

Postal / Zip Code

TENANTS ONLY

Please be advised of tenant eligibility to request a mediation ONLY if a violation has occurred in at least one of the following areas below and written notice, via certified mail, has been given to the landlord/property manager within specified time frames according to the Uniform Residential Landlord Tenant Act

https://yourlegalaid.org/resources

https://apps.legislature.ky.gov/law/statutes/statute.aspx?id=3572

Lease violation(s)
https://yourlegalaid.org/resources
Building Code violations
https://louisvilleky.gov/government/codes-regulations
https://louisvilleky.gov/government/codes-regulations/property-maintenance-code-enforcement
Violations of the Uniform Residential Landlord Tenant Act (URLTA)
https://apps.legislature.ky.gov/law/statutes/chapter.aspx?id=39159
https://apps.legislature.ky.gov/law/statutes/statute.aspx?id=35729
Conflict in interpretations of URLTA and/or the Kentucky Landlord Tenant Law and/or lease agreement and/or building code violations
https://apps.legislature.ky.gov/law/statutes/chapter.aspx?id=39159

I agree to submit required forms and/or documentation (i.e. copy of written notice specifying violation, certified mail receipt confirming written notice, total amount of “back-rent” due, maintenance receipts, photos and/or visual recordings of violations, monthly rental rate and current/signed lease agreement, etc.) within five business days of my scheduled mediation and attend mediation with my landlord/property manager in an attempt to avoid an eviction filing.*

Please initial

I have given written notice of a specific lease violation and/or building code violation and/or a violation of URLTA and/or the Kentucky Landlord Tenant Law to my landlord/property manager within guidelines of the Uniform Residential Landlord Tenant Act (URLTA) via certified mail*

Please initial

Despite written notice within designated time frames, my landlord/property manager remains in violation of the lease agreement and/or URLTA and/or the Kentucky Landlord Tenant Law*

Please initial

I hereby waive normal procedural notice of a court date and agree to
receive notice of a court date from the assigned Mediator and/or
resolve: Restorative Practices LLC

Please initial*

Tenant hereby waives normal procedural notice to their court date and agrees to get notice of their court date from their mediator.

LANDLORDS ONLY

I agree to submit required forms and/or documentation (i.e. copy of written notice specifying violation, certified mail receipt confirming written notice, photos and/or recordings of violations current/signed lease agreement, monthly rent rate, at least a 90-day ledger documenting deficiency in rental payments and total amount of “back-rent” due, etc.) within five business days of my scheduled mediation and attend mediation with my tenant in an attempt to avoid filing an eviction.

Please initial*

I have given written notice of a specific lease violation and/or building code violation and/or a violation of URLTA and/or the Kentucky Landlord Tenant Law to my tenant within guidelines of the Uniform Residential Landlord Tenant Act (URLTA) via certified mail *

Please initial

Despite given written notice and designated time frames, my tenant remains in violation of the lease agreement and/or URLTA and/or the Kentucky Landlord Tenant Law.*

Please initial

I do not have a pending eviction filed against the party I am in dispute with and requesting a mediation for*

Please initial

I agree not to file an eviction against the party I am in dispute with per requesting an Eviction Prevention Mediation*

Please initial

I agree not to file an eviction against the party I am in dispute with throughout the Eviction Prevention Mediation process*

Please initial

I agree not to file an eviction against the party I am in dispute with throughout the Eviction Prevention Mediation process unless the disputing party fails to submit a Pre-Mediation Assessment Form and/or required documentation (i.e. copy of written notice specifying violation, certified mail receipt confirming written notice, total amount of “back-rent” due, maintenance receipts, photos and/or recordings of violations, monthly rental rate and current/signed lease agreement) within five business days of the scheduled mediation and/or fails to attend the scheduled mediation and/or fails to sign an Agreement to Mediate and/or fails to sign a Mediation Settlement Agreement.*

Please initial

"There are three sides to every story: your side, my side, and the truth. And no one is lying. Memories shared serve each differently".
- Robert Evans

LANDLORD(s): Please include the first/last name of the tenant within the
“Your side of the story” section

TENANT(s): Please include the first/last name of the landlord or
property manager within “Your side of the story” section

Your "side of the story"*

Three outcomes desired as a result of the mediation process.*

Additional “parties” directly involved in and/or impacted by the dispute:

N/A

All additional "disputing parties" fields are optional.

Name

First NameLast Name

Primary Contact Number

Primary Email Address

Name

First NameLast Name

Primary Contact Number

Primary Email Address

Name

First NameLast Name

Primary Contact Number

Primary Email Address

Please read our Privacy Policy

Entering your signature in the box below certifies that you have read and understand the contents of this Privacy Policy:*

Today's Date:*

The confidentiality of communications sent via the Internet cannot be guaranteed and the electronic submission of your Pre-Mediation Assessment request is purely voluntary.

You may also print the contents of the Pre-Mediation Assessment Form and submit it U.S. mail to:
ATTN: Principal Mediator, resolve: Restorative Practices LLC, P.O. Box 266, Louisville, KY 40201

I acknowledge and confirm that the information included in the EPM Pre-Mediation Assessment and any other information I have provided through this process, are true and accurate to the best of my knowledge. I understand that any attempt to submit false, inaccurate or misleading information may result in my removal from the mediation process.

Entering my signature in the box below certifies that I have read and understand the contents of this Pre-Mediation Assessment (i.e. Privacy Policy, etc.) that I am fully able and competent to complete it and the statements I have made herein true.*

Today's Date:*

I am the tenant, previous contact information applies

Required Tenant Contact Information

Full Name

First NameLast Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Primary Email Address

Primary Contact Number

Required Landlord or Property Manager Contact Information

Full Name

First NameLast Name

Employer

Position Title

Business Email Address

Primary Contact Number

Business Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Initial contact will be made by resolve: Restorative Practices LLC within three business days per receipt of the EPM Pre-Mediation Assessment Form