2. Relocation Assistance Payment Report Form

4. Pursuant to EC 8.425 (17)(e) a landlord must report a relocation payment to the City within 60 days of the payment date.

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-term
16. Number of Bedrooms in Rental Unit
18. Monthly rent amount*
19. Date Tenancy Began*
    Date Tenancy Began
20. Fixed-term rental agreement end date
    Fixed-term rental agreement end date

22. Property Owner Information

24. First Name*
25. Last Name*
27. Property Owner's Legal Entity Name (if applicable)
29. Email*
30. Phone*
32. Mailing Address*
34. City*
35. State*
36. ZIP*
38. Type of Ownership

    For example: Natural person, Trust, LLC

39. How many rental units do you own?

41. Property Management (if applicable)

43. Company Name
44. Phone
46. Email

48. Relocation Assistance Payment Information

50. Payment Amount*
51. Payment Date
    Payment Date
52. Reason for Relocation Assistance*
    -- Select One --No-cause evictionLandlord-based reason for evictionDeclined to renew a fixed-term rental agreementRent increase at the maximum allowed by state law
54. Who made the payment?

    1. Property Owner
    2. Property Management
55. Did you also pay state relocation assistance?*
    -- Select One --YesNo

57. Electronic Signature

59. This form is designed to be completed and signed by the legal owner(s) of the rental dwelling unit obligated to pay City relocation assistance. If someone other than the property owner/landlord is completing this form on behalf of the owner/landlord, the undersigned certifies that they are authorized to act on behalf of the property owner/landlord to complete this form. 
    
    I hereby certify that the above information, to the best of my knowledge is true and complete. I understand that I must inform Rental Housing Code Compliance immediately and in writing of any changes. I understand that a Landlord that fails to comply with any of the requirements set forth in EC 4.25(17)  shall be liable to the Tenant for an amount up to 3 times the monthly Rent as well as actual damages, Relocation Assistance, reasonable attorney fees and costs.

61. I am the:*

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

    1. Sign

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

66. 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:


68. 1. Receive an email copy of this form.
69. Email address

    This field is not part of the form submission.

70. Submit Submit and Print

* indicates a required field