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Unpaid Permanent Relocation Payment Complaint Form

  1. This form may be completed by a Tenant who believes they have not been paid the appropriate Permanent Relocation Payment as required by RMC 11.100 and RMC 11.102.

  2. Are you 62 years of age or older, Disabled, or is there at least one minor dependent child in the household?*

  3. REQUIRED proof to substantiate age (ID with date of birth), disability (receipt of disability benefits or assistance), or presence of minor, dependent children (birth certificate AND tax return with dependents claimed).

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

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

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

  7. Is any documentation specified above not included with this complaint? If yes, please 1) explain why you have not attached the documentation and 2) describe any testimony or evidence you or a witness would provide at a hearing to prove failure to provide the Relocation Payment that is owed.

  8. 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.*

  9. Signature Verification*

  10. Form Resubmission?

  11. Leave This Blank:

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