Tenant Referral Form

Landlord-Tenant Mediation Program

Please correct the errors described below.

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

Name of all other adult household members:

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

SECTION 3: Landlord Information

SECTION 4: Mediator Selection

Section 5: Mediation Certifications

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.