Excess Rent Refund Form (For: Landlords, Property Managers, and Authorized Agents)

2. Purpose
   This form shall be submitted by Landlords and Authorized Agents after the complete excess rent refund is provided to the Tenant. This form applies only to Landlords of Controlled Rental Units for which there is a Maximum Allowable Rent.

   This form shall be submitted by Landlords and Authorized Agents after the complete excess rent refund is provided to the Tenant. This form applies only to Landlords of Controlled Rental Units for which there is a Maximum Allowable Rent.

4. Please be advised: In lieu of filing a civil action, a Tenant may file an administrative complaint. A Landlord who demands, accepts, receives or retains any payment of Rent in excess of the Maximum Allowable Rent shall be liable for damages in the amount by which the payment or payments demanded, accepted, received, or retains exceeds the Maximum Allowable Rent (RMC 11.100.100(b)(1-2)).

6. Instructions

8. 1. Complete the following online form.

10. 2. Upload a PDF copy of the Cashier's Check provided to the Tenant.

12. 3. Click "Submit".

16. Rental Unit Information

18. Assessor Parcel Number (APN) *

20. House Number*

21. Street Name*

22. Street Type*
    -- Select One --AlleyAvenueBoulevardCircleCourtDriveHeightsLaneLoopParkwayPlacePathRoadStreetSquareTerraceWay

23. Apt #

25. City*

26. State*

27. Zip*

31. Tenant Information (Name on Cashier's Check)

33. Tenant First Name*

34. Tenant Last Name*

36. Phone*

37. Email

39. Tenant Mailing Address (if different from Rental Unit address listed above)

41. Street Number

42. Street Name

43. Street Type
    -- Select One --AlleyAvenueBoulevardCircleCourtDriveLaneParkwayPlaceRoadStreetWay

44. Apt #

46. City

47. State

48. Zip

52. Landlord Information

54. Landlord First Name*

55. Landlord Last Name*

57. Landlord Phone*

58. Landlord E-mail*

60. Landlord Mailing Address

62. Street Number*

63. Street Name*

64. Street Type*
    -- Select One --AlleyAvenueBoulevardCourtCircleDriveHeightsLaneLoopPlaceParkwayPathPointRoadStreetSqaureTerraceWay

65. Apt #

67. City*

68. State*

69. Zip*

73. Rent History

75. Date Tenant first rented the unit (mm/dd/yyyy):*
    Date Tenant first rented the unit (mm/dd/yyyy):

77. Base Rent (rent paid on July 21, 2015, or first date of tenancy thereafter):*

79. Date of last rent increase after July 21, 2015 (mm/dd/yyyy):*
    Date of last rent increase after July 21, 2015 (mm/dd/yyyy):

81. Amount of last rent increase:*

83. Number of months Excess Rent was collected (after December 30, 2016):*
    -- Select One --12345678910111213141516171819202122

85. Amount of Excess Rent Refund:*

    Enter the total amount of excess rent collected since December 30, 2016.

87. Supporting Documentation*

    Attach a copy of the cashier's check addressed to the Tenant.

89. Please note: Any records included with this form and submitted to the City of Richmond, Rent Board, or Rent Program may be subject to disclosure pursuant to the California Public Records Act.

93. Certification of Correctness of Information

95. Certification of Correctness of Information*

    Under penalty of perjury under the laws of the state of California, I hereby certify that the foregoing information and that contained in any attached sheets is true and correct to the best of my knowledge and belief.

    1. Certification of Correctness of Information
99. Signature

101. I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct.

103. First Name*

104. Last Name*

106. Date*
     Date

108. Signature Verification*

     1. By checking this box, you certify this is your valid signature for all legal purposes.

110. Form Resubmission?

     1. Check this box if you are resubmitting this form to correct an error.

Leave This Blank:


111. 1. Receive an email copy of this form.
112. Email address

     This field is not part of the form submission.

113. Submit

* indicates a required field