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CAC HOME
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+1-410-313-6440

GET HELP
GET INVOLVED
WHO WE ARE
DONATE
VOLUNTEER
LOGIN

Landlord Intake Form

– Step 1 of 3

Please provide some information about the property.

Contact Information

Landlord or Property Manager's Name *

First

Last

Phone *

Email *

Address *

Address Line 1

City

State

Zip Code

Property Information

Property Name (or Tenant Name)

Property Address *

Address Line 1

City

State

Zip Code

County *

Number of Units *

Housing Type

Single-family Home
Duplex/Townhouse
Mobile Home
Condo
Apartment
Mixed Housing Complex

Do you know if any of your tenants are receiving the following? Check all that apply.

OHEP Utility Bill Pay Assistance
Housing Choice Vouchers (HUD)
Supplement Nutrition Assistance Program (SNAP)
Temporary Assistance for Needy Families (TANF)
Supplemental Security Income (SSI)
Medicaid
Maryland Fuel Fund Assistance
DHCD Rehab Program
Baltimore Lead Hazard Control Program
I don’t know
Healthy Homes for Healthy Kids

Does the property have any of the following problems? Check all that apply.

Missing or broken windows or external doors
Mold or mildew
Active roof leaks
Any damage to ceilings
Electrical violations or hazards
None of the above
Plumbing leaks, moisture problems

Are there any other health, safety or structural conditions in the home you would like to address? Please explain below.

Would you like to add another property?

Yes
No

Property Information (#2)

Property Name (or Tenant Name)

Property Address *

Address Line 1

City

State

Zip Code

County *

Number of Units *

Housing Type

Single-family Home
Duplex/Townhouse
Mobile Home
Condo
Apartment
Mixed Housing Complex

Do you know if any of your tenants are receiving the following? Check all that apply.

OHEP Utility Bill Pay Assistance
Housing Choice Vouchers (HUD)
Supplement Nutrition Assistance Program (SNAP)
Temporary Assistance for Needy Families (TANF)
Supplemental Security Income (SSI)
Medicaid
Maryland Fuel Fund Assistance
DHCD Rehab Program
Baltimore Lead Hazard Control Program
I don’t know
Healthy Homes for Healthy Kids

Does the property have any of the following problems? Check all that apply.

Missing or broken windows or external doors
Mold or mildew
Active roof leaks
Any damage to ceilings
Electrical violations or hazards
None of the above
Plumbing leaks, moisture problems

Are there any other health, safety or structural conditions in the home you would like to address? Please explain below.

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