Landlord Application

Funding provided for this program by a Grant from DHCD/ERAP-HSS. Information collected on this form may be transmitted to the State of Vermont (DHCD/AOA) for compliance and monitoring purposes.

SECTION 1: Landlord Information (to be filled in by Landlord)

Landlord Name (if entity)

Landlord Date of Birth

Landlord Individual Name

Primary Phone Number

Cell Phone Number

Landlord Street Address

City

State

Zip Code

Is there a pending eviction action with the court?

No Yes

If yes, enter Docket No.

Is the tenant still living in the rental unit?

No Yes Other (Please explain)

If other, please explain

SECTION 2: Landlord Attorney Information (to be filled in by Landlord)

Do you have an attorney?

Yes

If yes, please fill in Attorney information below.

If no, you can skip the rest of this section

Landlord Attorney Name

Landlord Attorney Phone Number

Landlord Attorney Email

SECTION 3: Tenant Information

Tenant First Name

Tenant Last Name

Primary Phone Number

Cell Phone Number

Email address

Rental Street Address

Unit#

City

State

Zip Code

Mailing Address (if different)

City

State

Zip Code

Does your Tenant know you have applied?

Yes No

Will your Tenant be submitting an application?

Yes No Not sure

SECTION 4: Mediator Selection

Please review the brief description of the mediators at https://vtlandlord.com/pdfs/Mediator_Bios.pdf. Together choose from the following options or indicate first and second choice for each of you. If there is someone on the list that you do NOT want to have as your mediator, indicate that as well.

Brian Miller

Adam Powers

Tad Powers

Brian Sawyer

No Preference

We cannot agree on a Mediator, please assign one

Please do not assign:

SECTION 5: Mediator Certifications

Landlord check each statement to indicate you agree:

I am voluntarily participating in this mediation program and process.

I agree to use the mediator that is assigned to my application.

I understand that certain information will not be confidential, including this application, the Mediator Report, and any mediator evaluation that I provide.

I acknowledge that the mediation will be held virtually, and that I will ensure that I have access to the Zoom platform with a sufficient internet connection.

Landlord #1 Signature

Date

Landlord #2 Signature

Date

How did you hear about Us? (Check all that apply)

VT Landlord website

Facebook Ad

Facebook Post

Google Search

Vermont Legal Aid

Video Ad

Referral from _________________________

Other _____________________________

Hitting the submit button below will send your completed application to the mediation program. If you have questions about the status of your application please contact us at mediation@vtlandlord.com

Information collected on this form may be transmitted to the State of Vermont (DHCD/AOA) for compliance and monitoring purposes.

Your information will be encrypted.