Head of Housold Information: Male      Female           Ethnicity: Hispanic    Non-Hispanic       Race : Asian      Black       Caucasian      Native-American

                     Disability Status:    Yes        No                Veteran:     Yes           No

    Number of members in household (including head of household):      Less than 18 years old      Greater than or equal to 18 years old.

    Income per year: Less than $5000 ,     $5,000 to $9,999       $10,000 to $14,999      $15,000 to $19,999     Greater than $20,000

    Nature of Problem

            Substandard Housing Unit with a subsidy     Substandard Housing Unit without a subsidy
            Eviction with a subsidy   Eviction without a subsidy   Non-Payment   Cause       Additional Information:


    Service Provided / Outcome as of end of visit:
     Referral      Advocacy during mediation       Negotiate continuance for cash assistance eligibility      Promise of financial assistance       More Info.

     Was Tenancy Preserved?      Yes        No

     Organizations: Catholic Charities     Community Action      HAP       Springfield Partners       TPP      WMLS

      Other:         Referred to:

      Completed By:    Date: