Please provide the following contact information:

Full Name
Organization
Work Phone	Fax
E-mail
Date

State the precise name of the owner or management company of the premises:

Owner's Full Name
Business or Mgmt Co.

State the address of the owner or management company:

Street Address
City
State	Zip Code

State the name and address of the person who you are seeking to evict:

Tenant 1 Name
SSN	(if available)
Street Address
City	County
State	Zip Code

State the names of any other adult occupants, whether or not on the lease::

Tenant 2 Name
Tenant 2 SSN	(if available)
Tenant 3 Name
Tenant 3 SSN	(if available)
Tenant 4 Name
Tenant 4 SSN	(if available)

State the names of any other adult occupants not listed above, whether or not on the lease:

Do you have a written lease agreement?

Yes No

Grounds for eviction (please check all that apply):

Nonpayment of rent
Unauthorized occupant(s)
Pets in violation of lease agreement
Holdover of lease term
Other material breach of lease agreement

State the date the Notice to Vacate the Premises was served: 

If eviction was for nonpayment of rent, state the total amount due as of this date: $

State the monthly rent: $

If your grounds for eviction were other than nonpayment of rent, please elaborate:

State the name and address of the co-signor, if any:

Co-Sign Name
Street Address
City
State	Zip Code

State the name and address of any other co-signors:

Choose one of the following options:

Eviction only Eviction plus second cause for money due

Which payment method do you prefer:

            Bill me with payment due within 30 days Apply to my account with your office Call for credit card (if available) Call me to discuss payment terms and arrangements

Any other questions or comments for your lawyer: