CITY OF SAN JOSE
Eviction Help Center Survey
All personal identifying information is kept confidential and not used for any other purpose.

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Is this survey for yourself or others?

Self

Other Person

Preparer

First Name

Middle Initial

Last Name

Email

Phone #

Can we send you text?

Yes

No

Address

Address line 2

City

State Value is not selected

Zip Code

Council District (if known) Value is not selected

Are you the head of the household?

Yes

No

Number of Adults in Houeshold >18 years of age Value is not selected

Number of Minors in Houeshold < 18 years of age Value is not selected

Household Gross Income (before tax deductions) Value is not selected

Source of income (check all that apply)

Work

Unemployment

Social Security

SSI

CalWorks/Welfare

State Disability

VA Benefits

General Assistance

Other

Do you receive any of these? (Check all that apply.)

Medical

IHSS

Food Stamps

None

$

What do you need help with?

Past Due Rent

Future Rent

Eviction Prevention legal services

Other

Specify Other:

Have you received rental assistance from other sources? Value is not selected

Preferred Language(s): Values are not selected

Do you think you have received a termination or eviction notice or a Notice to Pay?

Yes

No

Unsure

Have you received an Unlawful Detainer?

Yes

No

If yes, when were you served the Unlawful Detainer?

Would you like us to contact you to schedule an appointment?

Yes

No

I have an appointment.

How did you hear about us? (check all that apply):

Other, please specify:

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Eviction Help Center Survey

DEMOGRAPHIC INFORMATION (Demographic information is used for statistical purposes only. Other information provided in this section is kept confidential.)

INFORMATION ABOUT YOUR HOUSING ISSUE