Case Information Sheet

Landlord's Name(Required)

Address(Required)

Street Address Apartment, suite, etc City State / Province / Region ZIP / Postal Code

Email Address(Required)

Tenant(Required)

Tenant's Name

Tenant's Email Address

Tenant's Phone Number

Address(Required)

Property Address Apartment, suite, etc City State / Province / Region ZIP / Postal Code

Is the tenant's rent subsidized?(Required)

Yes

Monthly Rental Amount(Required)

Please enter a number less than or equal to 9999999.

Due Date(Required)

Monthly Late Fee Amount(Required)

Please enter a number less than or equal to 9999999.

Total Amount Due *(Required)

Please enter a number less than or equal to 9999999.

Back Rent Description

Was the property built prior to 1978?(Required)

Yes

Is the property Registered with MDE?(Required)

Yes

Is the tenant in the Military?(Required)

Yes

Date

Owner's Signature