Eviction Submission Form Landlord/Owner Name * First Name Last Name Business or Company Name (if applicable) Landlord/Owner Address Address 1 Address 2 City State/Province Zip/Postal Code Country Landlord/Owner Phone * (###) ### #### Landlord/Owner Email * List names of all adult tenants * Rental Property Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Tenant Email Tenant Phone (###) ### #### Monthly Rent Amount $ * Number of Months Behind in Rent: *required if eviction is due to delinquent rent 1 2 3 4 5 6 7 8 9 10 11 12+ Total Amount of Rent Due $: *required if eviction is due to delinquent rent First Date of Delinquent Rent MM DD YYYY Is there a written lease agreement? * Yes, there is a written lease There is a verbal agreement No, there is no written lease or agreement Government Subsidized? (Section 8) * No Yes If Government Subsized: list monthly $ amounts for government and tenant portions Is the tenant a military servicemember? * Yes No Unknown Authorization * By checking the box below I am authorizing Harmon & Associates Eviction & Legal Support Services, LLC and its agents to act as my authorized agent in the listed matter, having read and agree to the Terms & Conditions. I authorize Harmon & Associates Eviction & Legal Support Services, LLC to act as my authorized agent. Thank you for your business! We will review your case and contact you soon.
