Lease Assistance Intake Form

Lease Assistance Intake Form
Name*
First NameLast Name
Current Address*
Street Address
Street Address Line 2
CityState / Province
Postal / Zip Code
What is your Date of Birth?*
What is your relationship status?*
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Is it safe to call you on your phone listed above?
YesNoOnly at certain times of the day
What is the safest and/or best time of time to call you?
I am seeking to be released from my lease because I am a victim of:*
Domestic ViolenceSexual AssaultStalking
I have experienced the following forms of abuse:*
Physical Abuse (Hitting; punching; pushing; biting; strangulation; grabbing, etc.)Sexual Abuse (Sexual assault; rape; sexual/reproductive coercion; threats of harm if you do not agree to sex; etc.)Emotional/Verbal Abuse (Name-calling; threats of violence; threats of suicide; threats of child abduction; shaming; unfounded accusations of cheating; etc.)Being held against your will (Refusing to let you leave your home; taking your car keys or other actions to prevent you from leaving home; locking you in a room, physically holding you down or refusing to permit you to leave the room; etc.)Financial Abuse (Taking/stealing your money; controlling your finances; cutting off access to accounts, bank cards, credit cards; requiring you to complete tasks in order to have access to your money; opening accounts in your name without your consent; attempts to get you fired from your job; failing to adhere to an agreed upon schedule so you do not have childcare; etc.)Isolation from friends and family (Getting angry if you spend time with others; searching your phone; telling you who you can be friends with; forcing you to choose between them and your family; etc.)Stalking (Following you; spying on you; adding tracking devices to your phone or vehicle; using cameras to watch you in your home; etc.)
Please provide the approximate date of the most recent incident of abuse.
MonthDayYear
Date
What is the name of your abuser?
First NameLast Name
Do you currently reside with your abuser?
YesNo
Is the address listed above the same address for which you are requesting to be released from a lease?
YesNo
If the address listed above is NOT the address for which you are requesting to be released from a lease, please add that address here:
Street Address
Street Address Line 2
CityState / Province
Postal / Zip Code
What is the Name/Company of your landlord?*
How much is your rent?
How much longer do you have left on your lease? (In months)
Are you presently in eviction proceedings?*
YesNo
Do you have a Final Protection Order against your abuser?*
YesNo
Are there any criminal charges currently pending against your abuser as a result of abusing you?
YesNoDon't know
Would you like to discuss pursuing a protection order? (When a final protection order is granted, it may be used to be released from your lease, in addition to providing additional protections.)
YesNo
INCOME/HOUSEHOLD INFORMATION:
The following information is for ACME grant funding purposes only. Your income does not determine your eligibility to be released from your lease and is not a factor we consider when determining whether or not we will be able to assist you with this service.
What is your current annual income?
How many members do you have in your household? (Include yourself and any minor children)
The majority of ACME's work is funded by grants. The following questions are based upon the data that we are required to collect. You are not required to respond to these questions but we always appreciate it if you do.
What is your gender?
Are you transgender?
What is your race?
Native American/Alaskan NativeAsianPacific IslanderBlack/African AmericanLatino/HispanicNative HawaiianWhite, Not of Hispanic OriginDecline to AnswerOther
I solemnly affirm that the contents of the foregoing document are true to the best of my knowledge, information, and belief.
Signature of Client
Clear
Date signed by Client
MonthDayYear
Date
LEASE RELEASE ASSISTANCE DISCLOSURE:
I understand that ACME provides this service only due to domestic violence, sexual assault, and/or stalking, and as permitted by ACME Real Property Code 1-A-23 (2024).
I understand completion of this intake is not a guarantee of services.
I understand that ACME's assistance with being released from my lease shall not be construed as creating an ongoing attorney/client relationship. We do not represent clients in eviction hearings and we are not able to assist with any further legal disputes that may arise with the landlord as the result of the termination of your lease, including but not limited to, the release of your security deposit or the cost of any damages to the property itself. If any such issues arise, we are happy to provide you with a referral.
With my signature below, I acknoweldge the disclosure of this information.
Signature
Clear
Date
MonthDayYear
Date
Should be Empty: