Proof of Permanent Relocation Payment Form (For: Landlords, Property Managers, and Authorized Agents)

2. Purpose

4. This form shall be completed after EACH Permanent Relocation Payment portion is disbursed to the Tenant.
   In accordance with Section 11.102.070(e) of the Relocation Ordinance, a Landlord shall within three business days of providing a Tenant with a Temporary Relocation Payment, a Rent Differential Payment or a Permanent Relocation Payment file with the Rent Board a proof of service with the time and date when the Landlord made such Payment.

   In accordance with Section 11.102.070(e) of the Relocation Ordinance, a Landlord shall within three business days of providing a Tenant with a Temporary Relocation Payment, a Rent Differential Payment or a Permanent Relocation Payment file with the Rent Board a proof of service with the time and date when the Landlord made such Payment.

6. Instructions

8. 1. Complete all required fields in the form below.

10. 2. Upload (a) documentation of the payment (e.g. copy of cashier's check) and (b) a Proof of Service.

14. Rental Unit Information

16. Assessor Parcel Number (APN) *

18. House Number*

19. Street Name*

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

21. Apt #

23. City*

24. State*

25. Zip*

29. Tenant Information

31. Tenant First Name*

32. Tenant Last Name*

34. Phone*

35. Email

37. Current Mailing Address

39. Street Number*

40. Street Name*

41. Street Type*
    -- Select One --AlleyAvenueBoulevardCircleCourtDriveLaneParkwayPlaceRoadStreetWay

42. Apt #

44. City*

45. State*

46. Zip*

50. Additional Information

52. Additional Tenant Information
    Please list the name(s) of any other individuals on the lease or rental agreement.

    Please list the name(s) of any other individuals on the lease or rental agreement.

54. First Name

55. Last Name

57. First Name

58. Last Name

60. First Name

61. Last Name

63. First Name

64. Last Name

66. First Name

67. Last Name

69. Qualified Tenant Household Information

71. Is there at least one Tenant (in the household) that is a Senior Citizen?*
    -- Select One --YesNo

73. Is there at least one Tenant (in the household) that is Disabled?*
    -- Select One --YesNo

75. Is there at least one Tenant (in the household) that is a minor, dependent child?*
    -- Select One --YesNo

77. Landlord Information

79. Landlord First Name*

80. Landlord Last Name*

82. Landlord Phone*

83. Landlord E-mail*

85. Landlord Mailing Address

87. Street Number*

88. Street Name*

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

90. Apt #

92. City*

93. State*

94. Zip*

98. Termination of Tenancy Information

100. Reason for Termination of Tenancy*
     -- Select One --Owner Move-InWithdrawal from the Rental Market

102. Please attach a PDF copy of the Notice of Entitlement to Permanent Relocation Payment that was given to the Tenant.*

104. Has the Tenant notified the Landlord in writing of the date when they will vacate the Unit?*
     -- Select One --YesNo

106. If you answered yes to the previous question, please give the date the Tenant indicated they will vacate the Rental Unit by.
     If you answered yes to the previous question, please give the date the Tenant indicated they will vacate the Rental Unit by.

107. If you answered yes to the previous question, please attach a PDF copy of the written notice of vacation date the Tenant gave the Landlord.

109. Total Relocation Payment Amount Due to Tenant:*

111. Total Relocation Payment Amount Paid (to date):*

113. Supporting Documentation*

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

115. 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.

119. Certification of Correctness of Information

121. 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
125. Signature

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

129. First Name*

130. Last Name*

132. Date*
     Date

134. Signature Verification*

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

136. Form Resubmission?

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

Leave This Blank:


138. 1. Receive an email copy of this form.
139. Email address

     This field is not part of the form submission.

140. Submit

* indicates a required field