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2. 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.
4. 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)).
6. Instructions
8. 1. Complete the following online form.
10. 2. Upload a PDF copy of the Cashier's Check provided to the Tenant.
12. 3. Click "Submit".
16. Rental Unit Information
18. Assessor Parcel Number (APN) *
20. House Number*
21. Street Name*
22. Street Type*
    -- Select One --AlleyAvenueBoulevardCircleCourtDriveHeightsLaneLoopParkwayPlacePathRoadStreetSquareTerraceWay
23. Apt #
25. City*
26. State*
27. Zip*
31. Tenant Information (Name on Cashier's Check)
33. Tenant First Name*
34. Tenant Last Name*
36. Phone*
37. Email
39. Tenant Mailing Address (if different from Rental Unit address listed above)
41. Street Number
42. Street Name
43. Street Type
    -- Select One --AlleyAvenueBoulevardCircleCourtDriveLaneParkwayPlaceRoadStreetWay
44. Apt #
46. City
47. State
48. Zip
52. Landlord Information
54. Landlord First Name*
55. Landlord Last Name*
57. Landlord Phone*
58. Landlord E-mail*
60. Landlord Mailing Address
62. Street Number*
63. Street Name*
64. Street Type*
    -- Select One --AlleyAvenueBoulevardCourtCircleDriveHeightsLaneLoopPlaceParkwayPathPointRoadStreetSqaureTerraceWay
65. Apt #
67. City*
68. State*
69. Zip*
73. Rent History
75. Date Tenant first rented the unit (mm/dd/yyyy):*
    Date Tenant first rented the unit (mm/dd/yyyy):
77. Base Rent (rent paid on July 21, 2015, or first date of tenancy thereafter):*
79. Date of last rent increase after July 21, 2015 (mm/dd/yyyy):*
    Date of last rent increase after July 21, 2015 (mm/dd/yyyy):
81. Amount of last rent increase:*
83. Number of months Excess Rent was collected (after December 30, 2016):*
    -- Select One --12345678910111213141516171819202122
85. Amount of Excess Rent Refund:*
    Enter the total amount of excess rent collected since December 30, 2016.
87. Supporting Documentation*
    Attach a copy of the cashier's check addressed to the Tenant.
89. 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.
93. Certification of Correctness of Information
95. 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.

    1. Certification of Correctness of Information
99. Signature
101. I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct.
103. First Name*
104. Last Name*
106. Date*
     Date
108. Signature Verification*

     1. By checking this box, you certify this is your valid signature for all legal purposes.
110. Form Resubmission?

     1. Check this box if you are resubmitting this form to correct an error.
Leave This Blank:


112. 1. Receive an email copy of this form.
113. Email address

     This field is not part of the form submission.

114. Submit

* indicates a required field