Full Name *

First Name

Last Name

Pronouns

Please share your pronouns. Pronouns are the part of speech used to refer to someone in the third person. We want to know how to respectfully refer to you.

she/her

he/him

they/them

ze/hir

no pronoun

no preference

not listed

Date of Birth *

MM

DD

YYYY

Primary Phone *

Country

(###)

###

####

Safety *

Is the above number a safe number to reach you?

Yes

No

Secondary Phone

(if needed)

Country

(###)

###

####

Email *

Do you have an email address?

Yes

No

Residential Address *

Please state the residential address involving your legal issue, if different from your current residential and/or mailing address.

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Mailing Address

What is your current mailing address, if different from the residential address listed above? If it is the same as above, please leave this question blank.

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Paperwork *

Preferred method to receive paperwork

Email

Mail

ERAP *

Have you ever submitted an Emergency Rental Assistance Program Application (ERAP)?

Yes

No

If yes, on what date?

MM

DD

YYYY

Are you a Cornell student? *

Yes

No

Identity *

Please check all that apply.

Individual with a diagnosed Disability

Survivor of Domestic Violence

Served in the Military

N/A or Prefer not to say

Military

Excluding yourself, has anyone in your household or family served in the military?

Yes

No

Veterans Law Practicum

Would you like free legal assistance on any veteran-related issues, like discharge upgrades or VA disability benefits?

Yes

No

Branch of Service

Please select the branch you served in.

Army

Marine Corps

Navy

Air Force

Space Force

Coast Guard

Landlord Name *

First Name

Last Name

Adverse Parties *

Select any of the following parties with whom you are having an issue.

Landlord

Property Manager

Co-tenant

Sublessor

Subtenant

Other tenant

Someone else

Lease *

Do you have a written lease?

Yes

No

Request *

Are you looking for legal advice? or for someone to represent you in court? Please note that we can only represent clients in the following counties: Tompkins, Tioga, Steuben, Schuyler, Chemung, Monroe, and Allegany.

Legal Advice

Court Representation

Issue *

Eviction Notice

Security Deposit

Lease, Rent, and Fees

Rent Regulated Apartment

Notices and Entry

Habitability and Repairs

Discrimination

Emergency Situation

Other

Urgency

Please check any boxes that apply for priority assistance.

Threat to personal safety

Time-sensitive housing issue (5 day limit)

Received court papers

Received eviction notice

Court Date

If you have an upcoming court date, when is it?

MM

DD

YYYY

Court Time

Hour

Minute

Second

AM PM

Start Date

When did your issue approximately start?

MM

DD

YYYY

LawNY *

Have you contacted LawNY at (607) 273-3667?

Yes

No

LawNY *

If yes, is LawNY currently assisting you?

Yes

No

N/A

Unsure

LawNY *

If you answered "Unsure" to the question above, will you allow us to contact LawNY on your behalf?

Yes

No

N/A

References *

Who referred you to us?

LawNY

Ithaca Tenants Union

Human Services Coalition

Ithaca Housing Collective

Cornell Off-Campus Living Office

CornellHealth Victim Advocacy Program

Someone else

Was not referred

Intake Volunteer Name

If you are completing this form on behalf of someone else, please state your name below.

First Name

Last Name