Tenant intake form

1
Name* This field is required.
First Name
Last Name
2
If other, who referred you to CEDP?
3
Best contact phone
Area Code
Phone Number
4
How long have you lived in this home?
Less than 6 months
6 to 11 months
1 to 2 years
3 to 4 years
5 to 10 years
10+ years
5
Please specify your current housing type:
Renter - Unsubsidized
Renter - Tenant-Based Rental Subsidy (Voucher)
Renter - Project-Based Rental Subsidy (Project-based Section 8, low-income housing)
Unofficial Renter - Couch Surfing, Double Up
Currently experiencing homelessness
6
What county do you currently live in?
Denver County
El Paso County
Arapahoe County
Jefferson County
Adams County
Larimer County
Douglas County
Boulder County
Weld County
Pueblo County
Mesa County
Broomfield County
Garfield County
La Plata County
Eagle County
Fremont County
Montrose County
Summit County
Delta County
Morgan County
Montezuma County
Elbert County
Routt County
Teller County
Logan County
Chaffee County
Otero County
Pitkin County
Park County
Gunnison County
Alamosa County
Grand County
Las County
Archuleta County
Moffat County
Prowers County
Rio Grande County
Yuma County
Clear Creek County
Conejos County
San Miguel County
Lake County
Kit Carson County
Huerfano County
Saguache County
Rio Blanco County
Gilpin County
Bent County
Crowley County
Lincoln County
Washington County
Ouray County
Custer County
Phillips County
Costilla County
Baca County
Sedgwick County
Ceyenne County
Dolores County
Kiowa County
Jackson County
Hinsdale County
Mineral County
San Juan County
7
Residence address
Street Address
Street Address Line 2
City
State
Zip Code
Please Select
Please Select
United States
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
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
8
What is your preferred method of communication?
Phone
Email
Text
9
What is the best time to contact you?Please select all times that apply. If there's a specific time that applies like a lunch break, please let us know at the end of the form
Early morning (7 AM- 9 AM)
Mid-morning (9 AM - 11 AM)
Middle of the day (11 AM -1 PM)
Early Afternoon (1 PM - 3 PM)
Afternoon (3 PM - 5 PM)
Evening (5 PM - 7PM)
10
Best contact email
example@example.com
11
What is your current, typical monthly income?Please estimate to the best of your ability. We understand that income may be variable week to week or month to month.
12
Number of individuals currently in your household
13
Landlord name
First Name
Last Name
14
If not, when do you anticipate being behind on rent?
15
Landlord Email
example@example.com
16
What is your racial identity?
American Indian or Alaskan Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Other or Multi-racial
Prefer not to Answer
17
What is your ethnicity?
Hispanic or Latino
Non-Hispanic or Latina
Prefer not to answer
18
When is your next monthly rent payment due?
Date
Month
Day
Year
19
What is your monthly rent?
20
What is your gender identification?
Male
Female
Transgender Male
Transgender Female
Other
Prefer not to Answer
21
What are your preferred pronouns?
She / her / hers
He / him / his
They / them / theirs
Ze / hir, zir / hirs, zirs
Other
Prefer not to Answer
22
What is your date of birth?
Date
Month
Day
Year
23
If you are behind on rent, how much do you owe?Please provide the amount you owe your landlord (e.g., $1340)
24
Landlord Phone Number
Area Code
Phone Number
25
What is your primary language?
English
Spanish
Mandarin
Vietnamese
Amharic
Arabic
Somali
26
Are you currently behind on rent?
Yes
No
27
Please select all that apply:
One or more household members has a disability
One of more household members is 62 years old or older
Household is currently experiencing homelessness
One or more household members is on active duty or a military veteran
28
What communications, if any, have you had with your landlord?
29
Have you submitted an application for rental assistance with the state (ERAP)?If you have not applied, you can apply here: https://portal.neighborlysoftware.com/erap-colorado/participant
Yes - I submitted an application
I have started but not submitted
No - I have not submitted but will start an application now
No - I have not submitted
30
Do you receive housing assistance of any kind?
Yes
No
31
How did you hear about CEDP?
Adams County
CED / CSF Website
CEDP Law
Colorado Legal Services
Colorado Housing Connects
Colorado Poverty Law Project
Denver Indian Family Resource Center
Denver Rescue Mission
East Colfax Community Collective
ERAP agencies (DOH, Horne, Others)
ERAP System
Friend of CEDP
Lake County UNC
United for a New Economy (UNE)
9to5 Colorado
Full Circle of Lake County
Search Engine
Other Legal Aid Partner
Other Social Service Agency / Community Partner
Other Local Government Agencies
32
Please attach relevant documents (emails with landlord, screenshot of text messages, copy of lease, demands provided by landlords, other documents)
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
33
Has your landlord placed a "demand" or any other document on your door?
YESNO
34
If yes, describe
35
If you answered yes to the previous question (that you have received a summons), please tell us the court date.
Date
Month
Day
Year
36
Name* This field is required.
First Name
Last Name
37
Have your received a summons and complaint?This is an official document calling you to court. The complaint explains who is taking you to court and why. The summons tells you when and where you need to go for a hearing or when to answer the complaint.
YESNO
38
If you answered yes to the previous question (that your landlord has placed a demand on your door), please tell us the date that the demand will expire.
Date
Month
Day
Year
39
Anything else we should know?
40
If other, who referred you to CEDP?
41
Best contact phone
Area Code
Phone Number
42
How long have you lived in this home?
Less than 6 months
6 to 11 months
1 to 2 years
3 to 4 years
5 to 10 years
10+ years
43
Please specify your current housing type:
Renter - Unsubsidized
Renter - Tenant-Based Rental Subsidy (Voucher)
Renter - Project-Based Rental Subsidy (Project-based Section 8, low-income housing)
Unofficial Renter - Couch Surfing, Double Up
Currently experiencing homelessness
44
What county do you currently live in?
Denver County
El Paso County
Arapahoe County
Jefferson County
Adams County
Larimer County
Douglas County
Boulder County
Weld County
Pueblo County
Mesa County
Broomfield County
Garfield County
La Plata County
Eagle County
Fremont County
Montrose County
Summit County
Delta County
Morgan County
Montezuma County
Elbert County
Routt County
Teller County
Logan County
Chaffee County
Otero County
Pitkin County
Park County
Gunnison County
Alamosa County
Grand County
Las County
Archuleta County
Moffat County
Prowers County
Rio Grande County
Yuma County
Clear Creek County
Conejos County
San Miguel County
Lake County
Kit Carson County
Huerfano County
Saguache County
Rio Blanco County
Gilpin County
Bent County
Crowley County
Lincoln County
Washington County
Ouray County
Custer County
Phillips County
Costilla County
Baca County
Sedgwick County
Ceyenne County
Dolores County
Kiowa County
Jackson County
Hinsdale County
Mineral County
San Juan County
45
Residence address
Street Address
Street Address Line 2
City
State
Zip Code
Please Select
Please Select
United States
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
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
46
What is your preferred method of communication?
Phone
Email
Text
47
What is the best time to contact you?Please select all times that apply. If there's a specific time that applies like a lunch break, please let us know at the end of the form
Early morning (7 AM- 9 AM)
Mid-morning (9 AM - 11 AM)
Middle of the day (11 AM -1 PM)
Early Afternoon (1 PM - 3 PM)
Afternoon (3 PM - 5 PM)
Evening (5 PM - 7PM)
48
Best contact email
example@example.com
49
What is your current, typical monthly income?Please estimate to the best of your ability. We understand that income may be variable week to week or month to month.
50
Number of individuals currently in your household
51
Landlord name
First Name
Last Name
52
If not, when do you anticipate being behind on rent?
53
Landlord Email
example@example.com
54
What is your racial identity?
American Indian or Alaskan Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Other or Multi-racial
Prefer not to Answer
55
What is your ethnicity?
Hispanic or Latino
Non-Hispanic or Latina
Prefer not to answer
56
When is your next monthly rent payment due?
Date
Month
Day
Year
57
What is your monthly rent?
58
What is your gender identification?
Male
Female
Transgender Male
Transgender Female
Other
Prefer not to Answer
59
What are your preferred pronouns?
She / her / hers
He / him / his
They / them / theirs
Ze / hir, zir / hirs, zirs
Other
Prefer not to Answer
60
What is your date of birth?
Date
Month
Day
Year
61
If you are behind on rent, how much do you owe?Please provide the amount you owe your landlord (e.g., $1340)
62
Landlord Phone Number
Area Code
Phone Number
63
What is your primary language?
English
Spanish
Mandarin
Vietnamese
Amharic
Arabic
Somali
64
Are you currently behind on rent?
Yes
No
65
Please select all that apply:
One or more household members has a disability
One of more household members is 62 years old or older
Household is currently experiencing homelessness
One or more household members is on active duty or a military veteran
66
What communications, if any, have you had with your landlord?
67
Have you submitted an application for rental assistance with the state (ERAP)?If you have not applied, you can apply here: https://portal.neighborlysoftware.com/erap-colorado/participant
Yes - I submitted an application
I have started but not submitted
No - I have not submitted but will start an application now
No - I have not submitted
68
Do you receive housing assistance of any kind?
Yes
No
69
How did you hear about CEDP?
Adams County
CED / CSF Website
CEDP Law
Colorado Legal Services
Colorado Housing Connects
Colorado Poverty Law Project
Denver Indian Family Resource Center
Denver Rescue Mission
East Colfax Community Collective
ERAP agencies (DOH, Horne, Others)
ERAP System
Friend of CEDP
Lake County UNC
United for a New Economy (UNE)
9to5 Colorado
Full Circle of Lake County
Search Engine
Other Legal Aid Partner
Other Social Service Agency / Community Partner
Other Local Government Agencies
70
Please attach relevant documents (emails with landlord, screenshot of text messages, copy of lease, demands provided by landlords, other documents)
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
71
Has your landlord placed a "demand" or any other document on your door?
YESNO
72
If yes, describe
73
If you answered yes to the previous question (that you have received a summons), please tell us the court date.
Date
Month
Day
Year
74
Name* This field is required.
First Name
Last Name
75
Have your received a summons and complaint?This is an official document calling you to court. The complaint explains who is taking you to court and why. The summons tells you when and where you need to go for a hearing or when to answer the complaint.
YESNO
76
If you answered yes to the previous question (that your landlord has placed a demand on your door), please tell us the date that the demand will expire.
Date
Month
Day
Year
77
Anything else we should know?
78
If other, who referred you to CEDP?
79
Best contact phone
Area Code
Phone Number
80
How long have you lived in this home?
Less than 6 months
6 to 11 months
1 to 2 years
3 to 4 years
5 to 10 years
10+ years
81
Please specify your current housing type:
Renter - Unsubsidized
Renter - Tenant-Based Rental Subsidy (Voucher)
Renter - Project-Based Rental Subsidy (Project-based Section 8, low-income housing)
Unofficial Renter - Couch Surfing, Double Up
Currently experiencing homelessness
82
What county do you currently live in?
Denver County
El Paso County
Arapahoe County
Jefferson County
Adams County
Larimer County
Douglas County
Boulder County
Weld County
Pueblo County
Mesa County
Broomfield County
Garfield County
La Plata County
Eagle County
Fremont County
Montrose County
Summit County
Delta County
Morgan County
Montezuma County
Elbert County
Routt County
Teller County
Logan County
Chaffee County
Otero County
Pitkin County
Park County
Gunnison County
Alamosa County
Grand County
Las County
Archuleta County
Moffat County
Prowers County
Rio Grande County
Yuma County
Clear Creek County
Conejos County
San Miguel County
Lake County
Kit Carson County
Huerfano County
Saguache County
Rio Blanco County
Gilpin County
Bent County
Crowley County
Lincoln County
Washington County
Ouray County
Custer County
Phillips County
Costilla County
Baca County
Sedgwick County
Ceyenne County
Dolores County
Kiowa County
Jackson County
Hinsdale County
Mineral County
San Juan County
83
Residence address
Street Address
Street Address Line 2
City
State
Zip Code
Please Select
Please Select
United States
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
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
84
What is your preferred method of communication?
Phone
Email
Text
85
What is the best time to contact you?Please select all times that apply. If there's a specific time that applies like a lunch break, please let us know at the end of the form
Early morning (7 AM- 9 AM)
Mid-morning (9 AM - 11 AM)
Middle of the day (11 AM -1 PM)
Early Afternoon (1 PM - 3 PM)
Afternoon (3 PM - 5 PM)
Evening (5 PM - 7PM)
86
Best contact email
example@example.com
87
What is your current, typical monthly income?Please estimate to the best of your ability. We understand that income may be variable week to week or month to month.
88
Number of individuals currently in your household
89
Landlord name
First Name
Last Name
90
If not, when do you anticipate being behind on rent?
91
Landlord Email
example@example.com
92
What is your racial identity?
American Indian or Alaskan Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Other or Multi-racial
Prefer not to Answer
93
What is your ethnicity?
Hispanic or Latino
Non-Hispanic or Latina
Prefer not to answer
94
When is your next monthly rent payment due?
Date
Month
Day
Year
95
What is your monthly rent?
96
What is your gender identification?
Male
Female
Transgender Male
Transgender Female
Other
Prefer not to Answer
97
What are your preferred pronouns?
She / her / hers
He / him / his
They / them / theirs
Ze / hir, zir / hirs, zirs
Other
Prefer not to Answer
98
What is your date of birth?
Date
Month
Day
Year
99
If you are behind on rent, how much do you owe?Please provide the amount you owe your landlord (e.g., $1340)
100
Landlord Phone Number
Area Code
Phone Number
101
What is your primary language?
English
Spanish
Mandarin
Vietnamese
Amharic
Arabic
Somali
102
Are you currently behind on rent?
Yes
No
103
Please select all that apply:
One or more household members has a disability
One of more household members is 62 years old or older
Household is currently experiencing homelessness
One or more household members is on active duty or a military veteran
104
What communications, if any, have you had with your landlord?
105
Have you submitted an application for rental assistance with the state (ERAP)?If you have not applied, you can apply here: https://portal.neighborlysoftware.com/erap-colorado/participant
Yes - I submitted an application
I have started but not submitted
No - I have not submitted but will start an application now
No - I have not submitted
106
Do you receive housing assistance of any kind?
Yes
No
107
How did you hear about CEDP?
Adams County
CED / CSF Website
CEDP Law
Colorado Legal Services
Colorado Housing Connects
Colorado Poverty Law Project
Denver Indian Family Resource Center
Denver Rescue Mission
East Colfax Community Collective
ERAP agencies (DOH, Horne, Others)
ERAP System
Friend of CEDP
Lake County UNC
United for a New Economy (UNE)
9to5 Colorado
Full Circle of Lake County
Search Engine
Other Legal Aid Partner
Other Social Service Agency / Community Partner
Other Local Government Agencies
108
Please attach relevant documents (emails with landlord, screenshot of text messages, copy of lease, demands provided by landlords, other documents)
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
109
Has your landlord placed a "demand" or any other document on your door?
YESNO
110
If yes, describe
111
If you answered yes to the previous question (that you have received a summons), please tell us the court date.
Date
Month
Day
Year
112
Name* This field is required.
First Name
Last Name
113
Have your received a summons and complaint?This is an official document calling you to court. The complaint explains who is taking you to court and why. The summons tells you when and where you need to go for a hearing or when to answer the complaint.
YESNO
114
If you answered yes to the previous question (that your landlord has placed a demand on your door), please tell us the date that the demand will expire.
Date
Month
Day
Year
115
Anything else we should know?
116
If other, who referred you to CEDP?
117
Best contact phone
Area Code
Phone Number
118
How long have you lived in this home?
Less than 6 months
6 to 11 months
1 to 2 years
3 to 4 years
5 to 10 years
10+ years
119
Please specify your current housing type:
Renter - Unsubsidized
Renter - Tenant-Based Rental Subsidy (Voucher)
Renter - Project-Based Rental Subsidy (Project-based Section 8, low-income housing)
Unofficial Renter - Couch Surfing, Double Up
Currently experiencing homelessness
120
What county do you currently live in?
Denver County
El Paso County
Arapahoe County
Jefferson County
Adams County
Larimer County
Douglas County
Boulder County
Weld County
Pueblo County
Mesa County
Broomfield County
Garfield County
La Plata County
Eagle County
Fremont County
Montrose County
Summit County
Delta County
Morgan County
Montezuma County
Elbert County
Routt County
Teller County
Logan County
Chaffee County
Otero County
Pitkin County
Park County
Gunnison County
Alamosa County
Grand County
Las County
Archuleta County
Moffat County
Prowers County
Rio Grande County
Yuma County
Clear Creek County
Conejos County
San Miguel County
Lake County
Kit Carson County
Huerfano County
Saguache County
Rio Blanco County
Gilpin County
Bent County
Crowley County
Lincoln County
Washington County
Ouray County
Custer County
Phillips County
Costilla County
Baca County
Sedgwick County
Ceyenne County
Dolores County
Kiowa County
Jackson County
Hinsdale County
Mineral County
San Juan County
121
Residence address
Street Address
Street Address Line 2
City
State
Zip Code
Please Select
Please Select
United States
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
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
122
What is your preferred method of communication?
Phone
Email
Text
123
What is the best time to contact you?Please select all times that apply. If there's a specific time that applies like a lunch break, please let us know at the end of the form
Early morning (7 AM- 9 AM)
Mid-morning (9 AM - 11 AM)
Middle of the day (11 AM -1 PM)
Early Afternoon (1 PM - 3 PM)
Afternoon (3 PM - 5 PM)
Evening (5 PM - 7PM)
124
Best contact email
example@example.com
125
What is your current, typical monthly income?Please estimate to the best of your ability. We understand that income may be variable week to week or month to month.
126
Number of individuals currently in your household
127
Landlord name
First Name
Last Name
128
If not, when do you anticipate being behind on rent?
129
Landlord Email
example@example.com
130
What is your racial identity?
American Indian or Alaskan Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Other or Multi-racial
Prefer not to Answer
131
What is your ethnicity?
Hispanic or Latino
Non-Hispanic or Latina
Prefer not to answer
132
When is your next monthly rent payment due?
Date
Month
Day
Year
133
What is your monthly rent?
134
What is your gender identification?
Male
Female
Transgender Male
Transgender Female
Other
Prefer not to Answer
135
What are your preferred pronouns?
She / her / hers
He / him / his
They / them / theirs
Ze / hir, zir / hirs, zirs
Other
Prefer not to Answer
136
What is your date of birth?
Date
Month
Day
Year
137
If you are behind on rent, how much do you owe?Please provide the amount you owe your landlord (e.g., $1340)
138
Landlord Phone Number
Area Code
Phone Number
139
What is your primary language?
English
Spanish
Mandarin
Vietnamese
Amharic
Arabic
Somali
140
Are you currently behind on rent?
Yes
No
141
Please select all that apply:
One or more household members has a disability
One of more household members is 62 years old or older
Household is currently experiencing homelessness
One or more household members is on active duty or a military veteran
142
What communications, if any, have you had with your landlord?
143
Have you submitted an application for rental assistance with the state (ERAP)?If you have not applied, you can apply here: https://portal.neighborlysoftware.com/erap-colorado/participant
Yes - I submitted an application
I have started but not submitted
No - I have not submitted but will start an application now
No - I have not submitted
144
Do you receive housing assistance of any kind?
Yes
No
145
How did you hear about CEDP?
Adams County
CED / CSF Website
CEDP Law
Colorado Legal Services
Colorado Housing Connects
Colorado Poverty Law Project
Denver Indian Family Resource Center
Denver Rescue Mission
East Colfax Community Collective
ERAP agencies (DOH, Horne, Others)
ERAP System
Friend of CEDP
Lake County UNC
United for a New Economy (UNE)
9to5 Colorado
Full Circle of Lake County
Search Engine
Other Legal Aid Partner
Other Social Service Agency / Community Partner
Other Local Government Agencies
146
Please attach relevant documents (emails with landlord, screenshot of text messages, copy of lease, demands provided by landlords, other documents)
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
147
Has your landlord placed a "demand" or any other document on your door?
YESNO
148
If yes, describe
149
If you answered yes to the previous question (that you have received a summons), please tell us the court date.
Date
Month
Day
Year
150
Name* This field is required.
First Name
Last Name
151
Have your received a summons and complaint?This is an official document calling you to court. The complaint explains who is taking you to court and why. The summons tells you when and where you need to go for a hearing or when to answer the complaint.
YESNO
152
If you answered yes to the previous question (that your landlord has placed a demand on your door), please tell us the date that the demand will expire.
Date
Month
Day
Year
153
Anything else we should know?
154
If other, who referred you to CEDP?
155
Best contact phone
Area Code
Phone Number
156
How long have you lived in this home?
Less than 6 months
6 to 11 months
1 to 2 years
3 to 4 years
5 to 10 years
10+ years
157
Please specify your current housing type:
Renter - Unsubsidized
Renter - Tenant-Based Rental Subsidy (Voucher)
Renter - Project-Based Rental Subsidy (Project-based Section 8, low-income housing)
Unofficial Renter - Couch Surfing, Double Up
Currently experiencing homelessness
158
What county do you currently live in?
Denver County
El Paso County
Arapahoe County
Jefferson County
Adams County
Larimer County
Douglas County
Boulder County
Weld County
Pueblo County
Mesa County
Broomfield County
Garfield County
La Plata County
Eagle County
Fremont County
Montrose County
Summit County
Delta County
Morgan County
Montezuma County
Elbert County
Routt County
Teller County
Logan County
Chaffee County
Otero County
Pitkin County
Park County
Gunnison County
Alamosa County
Grand County
Las County
Archuleta County
Moffat County
Prowers County
Rio Grande County
Yuma County
Clear Creek County
Conejos County
San Miguel County
Lake County
Kit Carson County
Huerfano County
Saguache County
Rio Blanco County
Gilpin County
Bent County
Crowley County
Lincoln County
Washington County
Ouray County
Custer County
Phillips County
Costilla County
Baca County
Sedgwick County
Ceyenne County
Dolores County
Kiowa County
Jackson County
Hinsdale County
Mineral County
San Juan County
159
Residence address
Street Address
Street Address Line 2
City
State
Zip Code
Please Select
Please Select
United States
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
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
160
What is your preferred method of communication?
Phone
Email
Text
161
What is the best time to contact you?Please select all times that apply. If there's a specific time that applies like a lunch break, please let us know at the end of the form
Early morning (7 AM- 9 AM)
Mid-morning (9 AM - 11 AM)
Middle of the day (11 AM -1 PM)
Early Afternoon (1 PM - 3 PM)
Afternoon (3 PM - 5 PM)
Evening (5 PM - 7PM)
162
Best contact email
example@example.com
163
What is your current, typical monthly income?Please estimate to the best of your ability. We understand that income may be variable week to week or month to month.
164
Number of individuals currently in your household
165
Landlord name
First Name
Last Name
166
If not, when do you anticipate being behind on rent?
167
Landlord Email
example@example.com
168
What is your racial identity?
American Indian or Alaskan Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Other or Multi-racial
Prefer not to Answer
169
What is your ethnicity?
Hispanic or Latino
Non-Hispanic or Latina
Prefer not to answer
170
When is your next monthly rent payment due?
Date
Month
Day
Year
171
What is your monthly rent?