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Unpaid Permanent Relocation Payment Complaint Form

  1. Purpose

    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. Instructions

  3. 1. Complete the following online form.

  4. 2. Upload any supporting documentation (PDF format).

  5. 3. Click "submit".

  6. Complainant (Tenant) Information

  7. Current Mailing Address

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

  9. 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).

  10. Rental Unit Information

  11. Rental Unit Address

  12. Additional Tenant Information

  13. Additional Tenant #1 Information

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

  14. Current Mailing Address (if different from your current mailing address)

  15. Additional Tenant #2 Information

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

  16. Current Mailing Address (if different from your current mailing address)

  17. Additional Tenant #3 Information

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

  18. Current Mailing Address (if different from your current mailing address)

  19. Landlord Information

  20. Landlord Mailing Address

  21. Property Manager Information (if applicable)

  22. Property Manager Mailing Address

  23. Termination of Tenancy Information

  24. Required Documentation

  25. For your complaint to be accepted, you MUST upload PDF copies of the following documents (and any other documents you may believe are evidence) that Relocation Payment is owed and has not been paid. Please keep your original documents and bring them to any Rent Program meeting or hearing. You MUST submit the following documentation for your complaint to be processed.

  26. 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.

  27. Certification

  28. 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.*

  29. Signature

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

  31. Signature Verification*

  32. Form Resubmission?

  33. Leave This Blank:

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