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Eviction Prevention Assistance Screening Form

2. REFERRAL INFORMATION
4. First Name
5. Last Name
6. Date
   Date
8. FAMILY DEMOGRAPHICS
10. Parent/Guardian
11. Parent/Guardian
13. Address
14. Phone*
15. Email*
17. City
18. State
19. Zip
21. Parent/Guardian
22. Parent/Guardian
24. Address
25. Phone Number
26. Email
28. City
29. State
30. Zip
32. Children
34. First Name
35. Last Name
36. Gender
38. SSN
39. School
40. Grade
42. Address
43. City
44. State
45. Zip
47. First Name
48. Last Name
49. Gender
51. SSN
52. School
53. Grade
55. Address
56. City
57. State
58. Zip
60. First Name
61. Last Name
62. Gender
64. SSN
65. School
66. Grade
68. Address
69. City
70. State
71. Zip
73. First Name
74. Last Name
75. Gender
77. SSN
78. School
79. Grade
81. Address
82. City
83. State
84. Zip
86. First Name
87. Last Name
88. Gender
90. SSN
91. School
92. Grade
94. Address
95. City
96. State
97. Zip
99. Other Household Members
101. First Name
102. Last Name
103. Gender
105. SSN
106. Relationship to Children
107. Caregiver
109. First Name
110. Last Name
111. Gender
113. SSN
114. Relationship to Children
115. Caregiver
117. Reason for Referral/Needs
119. Housing Status
121. Pay or Quit Notice by Landlord

     1. No

     1. Yes
122. Deadline
     Deadline
124. Eviction Notice

     1. Yes
     2. No
125. Eviction Court Date:
     Eviction Court Date:
127. Amount Owed
128. Landlord Name
129. Landlord Contact Information
130. Recent Interventions and/or Agency Involvement:

     1. Yes
     2. No
Leave This Blank:


132. 1. Receive an email copy of this form.
133. Email address

     This field is not part of the form submission.

134. Submit

* indicates a required field