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

  1. Purpose
  2. This form shall be completed after EACH Temporary 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.
  3. Instructions
  4. 1. Complete all required fields in the form below.
  5. 2. Upload (a) documentation of the payment (e.g. copy of cashier's check) and (b) a Proof of Service.
  6. Rental Unit Information
  7. Tenant Information
  8. Current Mailing Address
  9. Additional Information
  10. Additional Tenant Information
    Please list the name(s) of any other individuals on the lease or rental agreement.
  11. Pet Accomodations
  12. Landlord Information
  13. Landlord Mailing Address
  14. Termination of Tenancy Information
  15. Attach a copy of the cashier's check or personal check addressed to the Tenant.
  16. 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.
  17. Certification of Correctness of Information
  18. 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.
  19. Signature
  20. I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct.
  21. Signature Verification*
  22. Form Resubmission?
  23. Leave This Blank:

  24. This field is not part of the form submission.