Baltimore County Eviction Prevention and Housing Stabilization Intake

Your Name

Street Address of the property you're contacting us about *

City and State *

Zip Code *

Your email address

Phone Number

Name of Landlord or Property Management Company *

Is English the primary language spoken in your household? *

Yes

No

Would you consider your English proficiency to be (pick one of the following) *

Good

Fair

No English Proficiency

What is the primary language spoken in your home?

Race (Due to Federal reporting regulations, please only choose one option) *

Are You Hispanic or Latinx? *

Yes

No

Your Gender (Due to Federal reporting regulations, please only choose one option) *

Your age *

Your total combined yearly household income, in whole dollars. Please include income for all family members/people living in your home. *

Your Monthly Rent Payment

Number of adults living in the home *

Number of children living in the home *

Do you receive a housing subsidy? (Tenants Only) *

Yes

No

If you receive a housing subsidy, please list the type of subsidy and the name of the agency that issued/manages your subsidy. (Tenants only)

Do you have a disability? *

Yes

No

Please describe your landlord-tenant issue here. (Please be as detailed as possible.) *

How did you hear about the Fair Housing Action Center of Maryland? *

The Fair Housing Action Center of Maryland works to advance an agenda of Fair Housing and housing equity in Maryland through legislative advocacy and research. Examples include signing a petition or contacting your elected officials. Would you be interested in hearing about opportunities to participate in the advocacy process? *

Yes

No

Would you be interested in sharing your story with the media? *

Yes, but only with all identifying information removed

Yes, and you may use my name.

Not interested at all.

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