2. Relocation Assistance Exemption Report Form

4. Pursuant to EC 8.425 (17)(g)5 a landlord must report exemptions under certain circumstances to the City in order to qualify for an exemption from the relocation assistance requirements. Regulated Affordable Housing units are not required to report their exemption.

6. Rental Dwelling Unit Information

8. Rental Dwelling Unit Address*
10. City*
11. State*
12. Zip Code*
14. Rental unit type (select one)
    -- Select One --Single family detachedDuplex, Triplex, quadplexApartment or condoCottage clusterAdditional Dwelling Unit (ADU)Manufactured home or mobile homeRoom in shared home
15. Rental Agreement type (select one)
    -- Select One --Month-to-monthFixed-termWeek-to-week
16. Date Tenancy Began*
    Date Tenancy Began
17. Fixed-term rental agreement end date
    Fixed-term rental agreement end date

19. Exemption Information

21. Exemption (select one) *
    -- Select One --1. Week-to-week tenancies 2. Landlord and tenant occupy the same dwelling3. Landlord and tenant occupy the same Middle Housing parcel 4. Landlord that rents a dwelling unit on a property with an ADU and lives on site 5. Landlord that temporarily rents out their Principal Residence for not more than 3 years 6. Landlord that temporarily rents out their Principal Residence due to active military service8. A dwelling unit impacted by the federal URA Act of 19709. A dwelling unit rendered immediately uninhabitable. 10. A dwelling unit rented for a period of 6 months or less with an previously submitted demolition permit11. Fixed term tenancy where the tenant was notified in advance of intent to sell or permanently convert the unit agreement

    Exemption 7. Regulated Affordable Housing units do not require reporting to the City.

23. Delivery Method of the Exemption Notice*
    -- Select One --Included in the Rental AgreementSeparate notice
24. Date the Notice was delivered to the tenant
    Date the Notice was delivered to the tenant

26. Property Owner Information

28. First Name*
29. Last Name*
31. Property Owner's Legal Entity Name (if applicable)
33. Email
34. Phone*
36. Physical Address*
38. Mailing Address (if different)
40. City*
41. State*
42. ZIP*

44. Property Management Information (if applicable)

46. Company Name
47. Phone
49. Email

51. Electronic Signature

53. By signing this form, I acknowledge that the tenant(s) residing in the rental dwelling unit address listed above have been notified of the exemption as required by EC 8.425(17)(g).

    
    

    This form is designed to be completed and signed by the legal owner(s) of the rental dwelling unit where exemption from the obligation to pay city relocation assistance is claimed. If someone other than the property owner/landlord is completing this form on behalf of the owner/landlord, the undersigned certifies that they are legally authorized to act on behalf of the property owner/landlord to complete this form. 

55. I am the:*

    1. Property Owner
    2. Property Owner's Agent
57. Electronic Signature*

    1. Sign

    By checking this box, I am providing an electronic signature.
58. Full Name*

60. IMPORTANT: Once you click Submit, you will not be able to edit your submission. Click "Save Progress" if you are not finished and you want to come back and edit.

Leave This Blank:


62. 1. Receive an email copy of this form.
63. Email address

    This field is not part of the form submission.

64. Submit Submit and Print

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