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Eviction Prevention Assistance Screening Form
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REFERRAL INFORMATION
First Name
Last Name
Date
Date
FAMILY DEMOGRAPHICS
Parent/Guardian
Parent/Guardian
Address
Phone
*
Email
*
City
State
Zip
Parent/Guardian
Parent/Guardian
Address
Phone Number
Email
City
State
Zip
Children
First Name
Last Name
Gender
SSN
School
Grade
Address
City
State
Zip
First Name
Last Name
Gender
SSN
School
Grade
Address
City
State
Zip
First Name
Last Name
Gender
SSN
School
Grade
Address
City
State
Zip
First Name
Last Name
Gender
SSN
School
Grade
Address
City
State
Zip
First Name
Last Name
Gender
SSN
School
Grade
Address
City
State
Zip
Other Household Members
First Name
Last Name
Gender
SSN
Relationship to Children
Caregiver
First Name
Last Name
Gender
SSN
Relationship to Children
Caregiver
Reason for Referral/Needs
Housing Status
Pay or Quit Notice by Landlord
No
Yes
Deadline
Deadline
Eviction Notice
Yes
No
Eviction Court Date:
Eviction Court Date:
Amount Owed
Landlord Name
Landlord Contact Information
Recent Interventions and/or Agency Involvement:
Yes
No
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