Habitability Intake Form

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2
Full Name
First Name
Last Name
3
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
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Algeria
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Cameroon
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Cape Verde
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Chile
China
Christmas Island
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Colombia
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Cuba
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Denmark
Djibouti
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Israel
Italy
Jamaica
Japan
Jersey
Jordan
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Kenya
Kiribati
North Korea
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Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
4
Email
example@example.com
5
Who Else Lives There?
Name
DOB
Adult
Row 0, Column 0
Row 0, Column 1
Adult
Row 1, Column 0
Row 1, Column 1
Child
Row 2, Column 0
Row 2, Column 1
Child
Row 3, Column 0
Row 3, Column 1
Adult
Adult
Child
Child
Name
Row 0, Column 0
DOB
Row 0, Column 1
Name
Row 1, Column 0
DOB
Row 1, Column 1
Name
Row 2, Column 0
DOB
Row 2, Column 1
Name
Row 3, Column 0
DOB
Row 3, Column 1
1 of 4
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Date Moved-In
Date
Year
Month
Day
7
Current Rent:
Rent Amount
8
Total Rooms
9
Do you have a copy of your lease agreement?
YESNO
10
If so, upload your full lease agreement
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
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11
Landlord Name
12
Landlord Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
13
Landlord Phone Number
Area Code
Phone Number
14
Property Management Name
15
Property Management Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
16
Property Management Phone Number
Area Code
Phone Number
17
Does the landlord live on the property?
YESNO
18
List All On-Going Habitability Issues
No Heat
No AC
Bed Bugs
Cockroaches
Spiders
Mice/Rats
Termites
No Hot Water
No Water
Electrical Issues
Other
19
List All On-Going Living Room Repair IssuesLiving Room
Ceiling Leaks
Mold/Mildew
Holes in Wall
Peeling Paint
Holes in Floor
Broken/Cracked Window
Buckled Floor
Damaged Window Casing
Holes in Carpet
Faulty Sockets/Switches
Other
20
List All On-Going Bedroom Repair IssuesBedroom
Ceiling Leaks
Mold/Mildew
Holes in Wall
Peeling Paint
Holes in Floor
Broken/Cracked Window
Buckled Floor
Damaged Window Casing
Holes in Carpet
Faulty Sockets/Switches
Other
21
List All On-Going Bedroom 2 Repair IssuesIf Applicable
Ceiling Leaks
Mold/Mildew
Holes in Wall
Peeling Paint
Holes in Floor
Broken/Cracked Window
Buckled Floor
Damaged Window Casing
Holes in Carpet
Faulty Sockets/Switches
Other
22
List All On-Going Bathroom Repair Issues
Ceiling Leaks
Mold/Mildew
Holes in Wall
Peeling Paint
Holes in Floor
Broken/Cracked Window
Buckled Floor
Damaged Window Casing
Holes in Carpet
Faulty Sockets/Switches
Other
23
List All On-Going Kitchen Repair Issues
Ceiling Leaks
Mold/Mildew
Holes in Wall
Peeling Paint
Holes in Floor
Broken/Cracked Window
Buckled Floor
Holes in Carpet
Faulty Sockets/Switches
Inoperable Refrigerator
No Hot Water
Inoperable Stove/Oven
No Cold Water
Other
24
Have you notified Management of the issues being submitted?
YESNO
25
If so, upload any written communicationScreenshot ANY Emails or Written Communication
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
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26
Do you feel you have been Harassed by Management?
YESNO
27
If so, what forms of harassment have you faced?
Illegal Entry: Entering the rental unit without proper notice or for non-legitimate reasons.
Utility Shutoffs: Shutting off utilities such as water, gas, or electricity to force the tenant out.
Lockouts: Changing the locks on the rental unit without providing the new keys to the tenant.
Verbal or Physical Threats: Intimidation, threats, or actual physical harm.
Intimidation and Coercion: Any form of intimidation or coercion, including threats to report the tenant to immigration authorities.
Unnecessary Construction: Performing construction or repairs that are unnecessary and intended to disturb the tenant.
Refusing Repairs: Deliberately refusing to perform necessary repairs to maintain the habitability of the unit.
Entering Without Notice: Entering the rental unit without giving proper notice as required by law, usually 24 hours for non-emergency situations.
Spying on Tenants: Any form of surveillance that invades the privacy of the tenant.
Excessive Communication: Overloading the tenant with unnecessary and frequent communications to create a nuisance.
False Accusations: Making false accusations of lease violations or other misdeeds.
Removing Tenant’s Possessions: Taking or removing the tenant’s personal property without permission.
Eviction Threats: Threatening eviction without proper legal grounds or using illegal eviction processes.
Discrimination: Harassment based on race, religion, gender, sexual orientation, disability, or other protected characteristics.
Other
28
Additional Comments
Huge
Large
Normal
Small
Ok
Ok
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Acknowledgement Statement for Habitability Intake

I, the undersigned, acknowledge that I have provided accurate and truthful information regarding the habitability conditions of my rental property located at the address mentioned above. I understand that the information I have provided will be used by TwinOak Law to assess the habitability issues and determine the appropriate legal actions to be taken on my behalf.
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I Affirm That:Check Each Box to Acknowledge
I have reported all known and relevant habitability issues affecting my rental unit, including but not limited to issues related to utilities, plumbing, heating, structural integrity, pest infestations, and other conditions that impact the livability of the premises.
I have supplied any supporting documentation, such as photographs, videos, and written communications with my landlord or property management, to assist in the evaluation of my case.
I am aware that TwinOak Law will review the information provided and may need to conduct further investigations, which may include on-site inspections, obtaining additional evidence, and communicating with relevant parties.
I understand that the success of my case may depend on the accuracy and completeness of the information I have provided.
I consent to TwinOak Law using the information I have provided for the purpose of legal representation in matters related to the habitability of my rental unit.
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Date
Date
Year
Month
Day
32
By signing below, I acknowledge that I have read, understood, and agree to the terms outlined in this statement.Client Signature
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