Tenant Defense Project of Greater Rochester Intake
Please forward
(1) Verification of all income sources
(2) Verification of all assets
(3) Copies of any notices received
(4) Copy of your lease, if you have one
(5) Copy of any court papers received
(6) Copies of any proof of payments made.
These documents should be emailed to tenanthelp@justcauseny.org
Personal Information
Are you currently working with any of the following regarding your housing matter or another legal matter?
Legal Assistance of Western New York, Inc. (LawNY)
Legal Aid Society of Rochester (LAS)
JustCause, Volunteer Legal Services Project of Monroe County, Inc. (VLSP)
Empire Justice Center (EJC)
Person completing intake with the client
Referred To
First Name
Last Name
Date of Birth
Last 4 of Social
Phone Number
Email
Is it safe to call and leave a voicemail at this number
Yes
No
Do you have ability to text?
Yes
No
Preferred contact method
Email
Phone
Text
Preferred Language
Please select...
English
Spanish
Afrikaans
Albanian
American Sign Language
Arabic
Armenian
Basque
Bengali
Bulgarian
Cambodian
Catalan
Chinese (Mandarin)
Croatian
Czech
Danish
Dari
Dutch
Estonian
Fiji
Finnish
French
Georgian
German
Greek
Gujarati
Hebrew
Hindi
Hungarian
Icelandic
Indonesian
Irish
Italian
Japanese
Javanese
Korean
Latin
Latvian
Lithuanian
Macedonian
Malay
Malayalam
Maltese
Maori
Marathi
Mongolian
Nepali
Norwegian
Pashto
Persian
Polish
Portuguese
Punjabi
Quechua
Romanian
Russian
Samoan
Serbian
Slovak
Slovenian
Somali
Swahili
Swedish
Tamil
Tatar
Telugu
Thai
Tibetan
Tonga
Turkish
Ukrainian
Urdu
Uzbek
Vietnamese
Welsh
Xhosa
Housing
Street Address
City/Town
ZIp Code
Is it safe to send mail to this address?
Yes
No
How long have you lived at this address?
What is your monthly rent amount?
Do you have a current written lease?
Yes
No
If you have a current lease, what is the time period of the lease?
Are you being evicted from the place you currently reside?
Yes
No
What is your eviction risk?
At risk for eviction
Subject to eviction
Not at risk
Have you sought emergency assistance such as Emergency Residential Assistance (ERA) program?
Yes, applied for assistance
Yes, approved for or received assistance
Yes, but denied assistance
No
Date applied to emergency assistance
How did you hear about the tenant defense project
Please select...
211
311
ABC-Action Front Center
Advertisement
Aids Care
AIDS Community Health Center
Anthony Jordan Health Center
ASADV
Attorney General's Office
Catholic Charities
Catholic Family Center
Catholic Family- Kinship Care
Center for Dispute Settlement (CDS)
Church Group
City of Rochester
Consumer Pilot Project
Cornell Farmworker Program
Domestic Violence Coalition
Empire Justice Center
Family/Friend
Family Court
Farmworker Legal Services
Federal Court
Finger Lakes Community Health
Habitat for Humanity
HEAL
Help Center
Highland Hospital
Housing Council
Human Service Agency
Huther Doyle
IBERO
Internet
Judicial Process Commission
LawNY
Lawyers Referral Service
Legal Aid Society
Lifespan
Lifetime
Live Help
MCBA Veteran's Committee
Medical-Legal
Monroe County Court
Monroe County Dept of Health
Monroe County DHS
Networks
NYSBA
Oak Orchard Health
Other Agency
Other LS Program
Pathstone
Police Department
Prior Client
Private Attorney
Private Bar
Public Defender
Radio Ad
Resolve
RIT
Rochester City Court
Rochester City School District
Rochester General Hospital
SBDC
SCORE
SELF-REFERRAL
Seniors Legal Services
State Court System
Strong Hospital
Supreme Court
Surrogates Court
Telephone Book
Tenant Defense Project
Threshold
TLC
Trillium Health
United Farmworkers
Urban League
VNS
Volunteer Legal Services
Westside Health Services
Willow
Worker's Center of Central NY
Worker Justice Center of NY
Are you a domestic violence survivor?
Yes
No
Are you a US Citizen?
Yes
No
If you are not a US Citizen, please advise regarding your current residency status.
Permanent Resident
Nonresident Alien
What best describes your gender?
Please select...
Female
Male
Trans Male
Trans Female
Gender Non-Conforming
Other Gender Identity
Are you a female head of household?
Yes
No
Have you or anyone in your household served in the military, reserves or national guard?
Please select...
I'm Active Duty or Reservist/Guard
I'm a Veteran or Veteran Retiree
A person in my household is Active Duty or Reservist/Guard
A person in my household is a Veteran or Veteran Retiree
None
Please provide name of veteran:
How do you identify your race?
Please select...
American Indian/Alaska Native
Asian
Biracial
Black/African American
Hispanic/Latino
Middle Eastern/North African
Native Hawaiian/Other Pacific Islander
White
Other
Prefer Not to Say
Unknown
Marital Status
Please select...
Married
Divorced
Widowed
Domestic Partner
Separated
Single
Total Adults (over the age of 18)
Total Children (under the age of 18)
Are there other people/children in your household besides you?
Yes
No
Other Household Members
First Name
Last Name
Date of Birth
Last 4 of Social
What best describes their gender?
Please select...
Female
Male
Trans Male
Trans Female
Gender Non-Conforming
Other Gender Identity
How do you identify their race?
Please select...
American Indian/Alaska Native
Asian
Biracial
Black/African American
Hispanic
Middle Eastern/North African
Native Hawaiian/Other Pacific Islander
White
Other
Prefer Not to Say
Unknown
Relationship to Client
Please select...
Husband
Wife
Child
Significant Other
Son
Daughter
Sibling
Step Child
Foster Child
Step Parent
Foster Parent
Guardian
Mother
Father
Biological Parent
Grandchild
Grandparent
Other
Does anyone in your household have a disability that significantly impacts their ability to live independently and that isn't expected to improve anytime soon?
Yes
No
Please provide the name(s) of the person(s) with the disability
Please select the disability(ies) that apply
Substance Abuse
Chronic Health Condition
Developmental
Mental Health Problems
Physical
Other
Other disability(ies)
Please select the option that most closely describes where you slept last night.
Apartment/other unit that you rent, no subsidy
Apartment/other unit that you rent, with subsidy (does not include payment by Department of Human Services)
Staying or living in a family member's room, apartment or house
Staying or living in a friend's room, apartment or house
Hotel or motel
Is rent for this unit subsidized a federal housing agency?
HUD Public Housing
HUD Housing Choice Voucher (Section 8)
HUD Project-Based Section 8
Low Income Housing Tax Credit (LIHTC)
Other
No
Other Subsidy Type
Amount of rental subsidy
Is your landlord a company or person?
Company
Person
I don't know my landlord's information
Is the evicting party a public housing agency (PHA)?
Yes
No
Who is your landlord (the person listed on court papers, if you have them) and/or someone else who is causing issues with your housing?
Landlord First Name
Landlord Last Name
Landlord Company Name
Landlord's Email
Landlord's Phone
In the past three years, how many times have you been on the streets or in a homeless shelter?
0
1
2
3
4 or more
In the past three years, how many total months have you spent on the streets or in a homeless shelter?
1 month (this is the first month)
2 to 4 months
5 to 7 months
8 to 10 months
11 to 12 months
More than 12 months
0 months
Income
Please list all household sources of income from all sources, gross monthly amounts, and who in household receives the amount. (Example of sources: Employment/job, unemployment insurance benefits, SSI/SSDI, Social Security Retirement Income, VA Benefits, Private Disability Insurance, Worker's Compensation, Public Assistance/TANF/Safety Net (please include case number), Pension, Child Support, Spousal Support, Other sources)
Income Type
Please select...
Child Support
Disability (Short Term, Long Term)
Employment - Gross (pre-tax) Wages
Employment - Other Household Member(s)
Self-employment
Family Member Contribution
No Income
Public Assistance / DSS
Rental Income
Retirement Benefits (401K, Pensions, etc)
Social Security Retirement
Spousal Support
SSD
SSI
Unemployment
Veterans Benefits
Workers Compensation
Please Note: If you select NO INCOME, you must still enter 0 for the Amount and select YEARLY for Frequency.
Other Income
Amount
Frequency
Please select...
Hourly
Weekly
Every 2 Weeks
Twice Monthly
Monthly
Yearly
Weekly Hours
Other Details/Who Receives
Do you anticipate that your income will change in the near future?
Yes
No
Future Income prospects are expected to Improve
Future Income prospects are expected to Improve
Future income prospects are expected to worsen
Does your household receive SNAP (food stamps) or WIC?
Yes
No
If receives SNAP, please provide monthly amount
Please select all types of health insurance you or other members of household have
Medicaid
Medicare
State Children's Health Insurance Program (CHIP)
Veteran's Administration (VA) Medical Services
Employer-Provided Health Insurance
Health Insurance obtained through COBRA
Private Pay Health Insurance
State Health Insurance for Adults
Indian Health Services Program
No Health Insurance
Other
If you have a bank account(s), please provide total in all accounts (if no bank account, please leave blank)
If you have cash on hand, please provide the total amount
If you own a recreational vehicle or other vehicle that is not used for your primary transportation, please provide the total value.
If you own real property other than where you live, please provide the total value.
If you own any stocks or bonds, please provide the total value.
If you were to sell all of your household goods and personal effects in a yard sale, how much would you get?
Do you have any other assets that you haven't already mentioned?
Yes
No
What kind of asset?
How much are they worth?
Do you have a court date scheduled?
Yes
No
If yes, what is the court date?
If yes, what time is your court appearance?
If yes, what Court is it in?
Please select...
Rochester City Court
Town/Village Court
County Court
State Court
Other State Court
Federal District Court
Federal Circuit Court
Briefly describe the nature of your housing issue (for example, currently facing eviction or hearing in ten days)
Is there any other important information/context that you were not able to explain above?
Do you give permission for the transfer and disclosure of information between Legal Assistance of Western New York, Inc., Legal Aid Society of Rochester, Empire Justice Center, Cornell’s Tenant Assistance Project, and JustCause, formerly Volunteer Legal Services Project of Monroe County, Inc.?
Yes
No
If you certify the information provided is true and accurate to the best of your knowledge, please sign your name here:
Date Signed
Contact Information