Housing Intake Form - Fair Housing Action Center of Maryland

I am a... *

Landlord

Tenant

Neither

Your Role and Job Title

Your Name *

Name of the Client/Person Who Needs Services *

Your email address *

Email Address of the Client/Person Who Needs Services *

Your phone number

Phone Number of the Client/Person Who Needs Services

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

City and State *

Zip Code *

County or City *

Name of Apartment Complex (if you live in an apartment) and Property Management Company or Landlord *

Race *

Gender *

Female

Male

Transgender

Other

Age *

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

Monthly rent or mortgage payment, in whole dollars

Number of adults living in the home *

Number of children living in the home *

Do you receive a housing subsidy? *

Yes

No

Please list the type of subsidy and the name of the agency that issued/manages your subsidy.

Do you have a disability? *

Yes

No

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

Please type your first and last name here. You affirm and certify that all the information and answers to questions herein are complete, true and correct to the best of your knowledge and belief. If you are filling this out on behalf of someone else, you would need to include your own name. *

Which organizations have you contacted about this issue before contacting us? *

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

Are you aware that Maryland has a Renter's Tax Credit? *

Yes

No

Would you like more information on the Maryland Renter's Tax Credit, or assistance with filling out the application?

Yes

No

Would you like to receive one-on-one financial counseling/coaching? *

Yes

No

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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