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.
Excess Rent Refund = Amount of overcharged rent (per month) x Number of months Excess Rent was collected (after December 30, 2016)
Attach a copy of the cashier's check addressed to the Tenant.
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.
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