Please provide the following information for the person who will be participating in the mediation as the Landlord, Property Manager, or Site Coordinator.
First Name *
Your answer
Last Name *
Your answer
Property Name, if applicable
Your answer
Street Address, Line 1 *
Your answer
Street Address, Line 2
Your answer
City *
Your answer
Zip Code *
Your answer
Participant Primary Phone Number *
Your answer
This Phone Is: *
Alternate Phone Number
Your answer
This Phone Is:
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DEMOGRAPHIC INFORMATION
Gender *
Age Range *
ETHNICITY *
RACE (Check all that apply) *
Required
MEDIATION LOGISTICS
Mediation will be arranged for a single, three-hour session after a preliminary phone call.
Do you have the INTERNET ACCESS, WEBCAM capability, and PRIVACY necessary to participate in a mediation by videoconference? *
Do you have any physical, language, or other accessibility needs to be able to participate in mediation?
Your answer
NATURE OF DISPUTE
Dispute Resolution Issues (Please check all that apply.) *
Required
If non-payment of rent is an issue in this case, would you accept rental assistance from an outside service provider to help the tenant pay back the balance owed?
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Please give additional details about the nature and background of the dispute. Describe any agreements or referrals.
Your answer
Has there already been a court filing with the magistrate for this dispute? *
Is this a unit subsidized through Section 8, a project-based voucher, or other types of public assistance? If your answer is YES, please specify.
Your answer
TENANT INFORMATION
Tenant First Name *
Your answer
Tenant Last Name *
Your answer
Property Name, if applicable
Your answer
Street Address, Line 1 *
Your answer
Street Address, Line 2
Your answer
City *
Your answer
Zip Code *
Your answer
Tenant Phone Number *
Your answer
Tenant Alternate Phone Number
Your answer
Tenant Email Address (if known)
Your answer
Is the tenant aware of and interested in mediation? *