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2. Purpose
4. This form shall be completed after EACH Permanent 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.
6. Instructions
8. 1. Complete all required fields in the form below.
10. 2. Upload (a) documentation of the payment (e.g. copy of cashier's check) and (b) a Proof of Service.
14. Rental Unit Information
16. Assessor Parcel Number (APN) *
18. House Number*
19. Street Name*
20. Street Type*
    -- Select One --AlleyAvenueBoulevardCircleCourtDriveHeightsLaneLoopParkwayPlacePathRoadStreetSquareTerraceWay
21. Apt #
23. City*
24. State*
25. Zip*
29. Tenant Information
31. Tenant First Name*
32. Tenant Last Name*
34. Phone*
35. Email
37. Current Mailing Address
39. Street Number*
40. Street Name*
41. Street Type*
    -- Select One --AlleyAvenueBoulevardCircleCourtDriveLaneParkwayPlaceRoadStreetWay
42. Apt #
44. City*
45. State*
46. Zip*
50. Additional Information
52. Additional Tenant Information
    Please list the name(s) of any other individuals on the lease or rental agreement.
54. First Name
55. Last Name
57. First Name
58. Last Name
60. First Name
61. Last Name
63. First Name
64. Last Name
66. First Name
67. Last Name
69. Qualified Tenant Household Information
71. Is there at least one Tenant (in the household) that is a Senior Citizen?*
    -- Select One --YesNo
73. Is there at least one Tenant (in the household) that is Disabled?*
    -- Select One --YesNo
75. Is there at least one Tenant (in the household) that is a minor, dependent child?*
    -- Select One --YesNo
77. Landlord Information
79. Landlord First Name*
80. Landlord Last Name*
82. Landlord Phone*
83. Landlord E-mail*
85. Landlord Mailing Address
87. Street Number*
88. Street Name*
89. Street Type*
    -- Select One --AlleyAvenueBoulevardCourtCircleDriveHeightsLaneLoopPlaceParkwayPathPointRoadStreetSqaureTerraceWay
90. Apt #
92. City*
93. State*
94. Zip*
98. Termination of Tenancy Information
100. Reason for Termination of Tenancy*
     -- Select One --Owner Move-InWithdrawal from the Rental Market
102. Please attach a PDF copy of the Notice of Entitlement to Permanent Relocation Payment that was given to the Tenant.*
104. Has the Tenant notified the Landlord in writing of the date when they will vacate the Unit?*
     -- Select One --YesNo
106. If you answered yes to the previous question, please give the date the Tenant indicated they will vacate the Rental Unit by.
     If you answered yes to the previous question, please give the date the Tenant indicated they will vacate the Rental Unit by.
107. If you answered yes to the previous question, please attach a PDF copy of the written notice of vacation date the Tenant gave the Landlord.
109. Total Relocation Payment Amount Due to Tenant:*
111. Total Relocation Payment Amount Paid (to date):*
113. Supporting Documentation*
     Attach a copy of the cashier's check or personal check addressed to the Tenant.
115. 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.
119. Certification of Correctness of Information
121. 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
125. Signature
127. I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct.
129. First Name*
130. Last Name*
132. Date*
     Date
134. Signature Verification*

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

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


138. 1. Receive an email copy of this form.
139. Email address

     This field is not part of the form submission.

140. Submit

* indicates a required field