Hirsch & Levy, L.L.C.- Intake Form

Please fill out intake form to start an eviction

Date
Your Name
Record Title Owner on Deed to the Premises
Your Address
Phone
Fax
Email
Tenant/All Adults
Premises Address/ All #'s of Bldg.
Apt./Floor
Lease	Oral Written
Rent due on	of the month
Total Monthly Rent $	If applicable, Government Subsidy/Section 8 Portion Tenant Portion
Move in Date
Tenant's Employment/Telephone #/ SS Number
Reason for Eviction
Repairs/Housing Code Violations
Do any occupants have a criminal record, mental illness or exhibit violent behavior? If yes, please explain
Any prior NTQ sent or correspondence in writing to tenant?
Specific instructions, if any, for the Marshal to gain access to the premises to serve papers

Please mail or fax to 203-331-1641 any written leases and/or correspondence.



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