WESTERN MASS NETWORK - HOUSING COURT RECORD OF SERVICE

CASE #       ZIP Code/City    /   

Household Type: Family  Individual

Number of members in household (including head of household):

less than 18    18 years and older

Head of Household Information:

Gender: Male    Female

Ethnicity:   Hispanic    Non-Hispanic

Race:    Black/African American    Asian    White    Native American

Disability?    Yes    No

Veteran?    Yes  No

Annual Income: $    OR    Monthly Income: $

Nature of Problem:

Substandard Housing Unit:

subsidy     non-subsidy

Eviction:

    subsidy      non-subsidy

    non-payment or cause One-time event? yes      no

     Additional Information:

Service Provided/Outcome as of end of visit:

Referred to

Advocacy during mediation         Advocacy with landlord/landlord's attorney (no court staff) 

 Screened for eligibility/intake appointment made to complete application and case continued

Additional Information

Was Tenancy Preserved? Yes    No

If no, what additional support/advocacy was provided:  

Organization Filling Out Form:

HAP      Catholic Charities    WMLS    Springfield Partners

   TPP      Community Action

Other:

Completed by:          Date: