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Tenants Assistance Program
Break Lease Data Required

Please be comprehensive in completing the following. This will allow us to best evaluate by what method we can proceed to help you terminate your rental tenancy, how long it might take, whether or not you will likely have to pay any more rent, and how much the service will cost you.

Generally, lease termination costs will be either 65% or 85% of a single month of rent, depending on the procedure utilized.

1. Today's Date:
2. Optimum desired move-out Date:
3. Have you used our service before?	yes no
4. If so, indicate approximately when, and in whose name that case was listed:
5. Your Name:
6. Email Address:
7. Name(s) of other tenants who have also signed the lease, list all:
8. Enter your cell phone, if any:
9. Enter your home phone, if any:
10. Enter your work phone, if any:
11. Enter your work phone extension, if any:
12. Enter an alternate phone we can reach you at, if any:
13. Enter the name of the person associated with your alternate phone number, if any:
14. Which phone is the best number to reach you at?	cell home work alternate
15. Dwelling type
16. Apartment Complex name, if any:
17. Current management company, if any:
18. Management contact person name and title, if any:
19. Property owner name, if any and known:
20. Property address from which trying to terminate: Street, Unit #, Town/City, Zip:
21. If apartment complex, indicate management office street address if different from property address:
22. Has the landlord, or the landlord’s agent, recently changed?	yes no don't know
23. If yes, describe the situation:
24. The date you originally moved into the dwelling:
25. Current lease term:
Is lease "Rent-to-Own"?	yes no
26. Date the current lease expires:
27. Amount of security deposit, if any:
28. Amount of other specific refundable deposits, if any, and purpose (e.g. cleaning, pets, etc.):
29. List non-refundable fees and purposes, if any (e.g. application, cleaning, pet, redecorating, etc.):
30. Rent payments due monthly or weekly?	monthly weekly
31. Rent payment per month or week:
32. List amount of additional advance rent held, if any:
33. Total rent discount offered (also known as concession, incentive, free rent), if any:
34. Are your rent payments current?	yes no
35. If already moved out, indicate when:
36. Do you still have keys to the premises, thus in possession?	yes no
37. Elaborate if needed:
38. Has the landlord currently locked you out of the dwelling?	yes no
39. If yes, describe:
40. Have you recently experienced a casualty in your dwelling, such as a flood, fire or serious destruction?	yes no
41. If yes, describe:
42. Are you the recent victim of an assault in your dwelling?	yes no
43. If yes, describe:
44. Are you the recent victim of domestic violence in your dwelling?	yes no
45. If yes, describe:
46. Is the landlord in, or heading towards: Bankruptcy, Foreclosure?	no bankruptcy - yes foreclosure -yes
47. If yes, describe:
48. Have you already given your landlord a written notice of your intent to vacate the dwelling?	yes no
49. If yes, describe:
50. Has the landlord given you notices of any alleged violations?	yes no
51. If yes, describe:
52. Are you facing any current court action to evict you?	yes no
53. If yes, describe:
54. What originally led to you (or a personal referral) finding or hearing about Arizona Tenants Advocates, or this website?
55. If 'other', describe:
56. Motivation for moving, if due to landlord failings, describe: Note: Do not list personal reasons for moving, such as buying house, medical, financial, employment, family status, etc. It is not essential that we know such underlying factors for us to help you.

Within 24 hours (excluding Sundays) from submission, a representative will telephone you at the numbers you have listed above. At that point we will discuss the options, set up an appointment with you, and tell you what documents you should bring to the appointment.

If you live remote from Maricopa County, it might be possible to conduct services via e-mail. Be advised: Cases in far-flung locations from Maricopa County may, but not necessarily, involve an excess inspector travel charge. Document delivery costs, such as postage or process service charges, are not included in our price.

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