PBRC EP Counselor Referral Form
Person completing form:
Tenant & Household Information
Tenant Name
Zip Code
Location
Baltimore City
Baltimore County
Phone number
Email address
Veteran?
Active
Veteran
N/A
Has children in household?
Yes
No
Is currently employed or receiving income?
Yes
No
Judgment & Eviction Information
Has an eviction date?
Yes
No
Date of eviction:
How far behind on rent?
Please select...
1 month or less
2 months or more
Unknown/Unsure
Amount needed to redeem:
Current client?
Yes
No
Previous Client
Unknown/Not Asked
Attorney/Paralegal Assigned to Case (if any)
Notes/Description:
Add supporting documents here, if applicable. Click "Add another response" to add more than one.
Please advise the tenant/caller that they will receive a response within 72 hours.
This submission will be automatically emailed PBRC's EP Counselor.
The contents of this submission will NOT export to SalesForce.
Contact Information