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Excess Rent Refund Form (For: Landlords, Property Managers, and Authorized Agents)
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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.
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)).
Instructions
1. Complete the following online form.
2. Upload a PDF copy of the Cashier's Check provided to the Tenant.
3. Click "Submit".
Rental Unit Information
Assessor Parcel Number (APN)
*
House Number
*
Street Name
*
Street Type
*
-- Select One --
Alley
Avenue
Boulevard
Circle
Court
Drive
Heights
Lane
Loop
Parkway
Place
Path
Road
Street
Square
Terrace
Way
Apt #
City
*
State
*
Zip
*
Tenant Information (Name on Cashier's Check)
Tenant First Name
*
Tenant Last Name
*
Phone
*
Email
Tenant Mailing Address (if different from Rental Unit address listed above)
Street Number
Street Name
Street Type
-- Select One --
Alley
Avenue
Boulevard
Circle
Court
Drive
Lane
Parkway
Place
Road
Street
Way
Apt #
City
State
Zip
Landlord Information
Landlord First Name
*
Landlord Last Name
*
Landlord Phone
*
Landlord E-mail
*
Landlord Mailing Address
Street Number
*
Street Name
*
Street Type
*
-- Select One --
Alley
Avenue
Boulevard
Court
Circle
Drive
Heights
Lane
Loop
Place
Parkway
Path
Point
Road
Street
Sqaure
Terrace
Way
Apt #
City
*
State
*
Zip
*
Rent History
Date Tenant first rented the unit (mm/dd/yyyy):
*
Date Tenant first rented the unit (mm/dd/yyyy):
Base Rent (rent paid on July 21, 2015, or first date of tenancy thereafter):
*
Date of last rent increase after July 21, 2015 (mm/dd/yyyy):
*
Date of last rent increase after July 21, 2015 (mm/dd/yyyy):
Amount of last rent increase:
*
Number of months Excess Rent was collected (after December 30, 2016):
*
-- Select One --
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
Amount of Excess Rent Refund:
*
Enter the total amount of excess rent collected since December 30, 2016.
Supporting Documentation
*
Attach a copy of the cashier's check addressed to the Tenant.
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.
Certification of Correctness of Information
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.
Certification of Correctness of Information
Signature
I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct.
First Name
*
Last Name
*
Date
*
Date
Signature Verification
*
By checking this box, you certify this is your valid signature for all legal purposes.
Form Resubmission?
Check this box if you are resubmitting this form to correct an error.
Leave This Blank:
Receive an email copy of this form.
Email address
This field is not part of the form submission.
Submit
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