Tenant Referral Form

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: Tenant Information (to be filled in by Tenant)

Tenant Name

Tenant Date of Birth

Tenant Qualification:

Households at or below 80% of area median income

Approved Reach Up ERA program (AHS/DCF)

Have not applied for Reach Up ERA program (AHS/DCF)

Name the above Application is under

Date Applied for Reach Up ERA program (AHS/DCF)

Primary Phone

Cell Phone

Email address

Rental Street Address

Unit#

City

State

Zip Code

Mailing Address (if different)

City

State

Zip Code

Name of all other adult household members:

#1 First Name

Last Name

#2 First Name

Last Name

#3 First Name

Last Name

#4 First Name

Last Name

#5 First Name

Last Name

Is there a pending eviction action with the Court?

No Yes

If yes, please provide Docket No.

Are you currently living in this rental unit?

No Yes Other (Please explain)

If other, please explain

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

Do you have an attorney?

Yes No (if no and you would like assistance, please authorize us to share your information with Vermont Legal Aid below and you can skip the Attorney information section)

Tenant check each statement to indicate you agree:

I authorize Vermont Landlord Association to communicate with Vermont Legal Aid, as applicable, regarding my participation in their Program.

I authorize Vermont Landlord Association and Vermont Legal Aid, as applicable, to share information I have provided to either program as needed.

Tenant Attorney Name

Tenant Attorney Phone Number

Tenant Attorney Email

SECTION 3: Landlord Information

Landlord Name (if entity)

Landlord Individual Name

Landlord Primary Phone Number

Landlord Cell Phone Number

Landlord Email Address

Landlord Street Address

City

State

Zip Code

Does your landlord know you have applied?

Yes No

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: Mediation Certifications

Tenant check each statement to indicate you agree:

I authorize Vermont Landlord Association to communicate with VERAP or AHS/DCF, as applicable, regarding my participation in their Program.

I authorize Vermont Landlord Association and VERAP or AHS/DCF, as applicable, to share information I have provided to either program as needed.

Tenant check each statement to indicate you agree:

I am voluntarily participating in this mediation program and process.

I agree to use the meditator 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.

Tenant 1 Digital Signature

Date

Tenant 2 Digital Signature

Date

Tenant 3 Digital Signature

Date

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

VT Landlord website

Facebook Ad

Facebook Page

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.