15-DAY NOTICE TO PAY RENT (WITH RENT-RELATED FEES)
NOTICE OF COVID-19 TENANT RELIEF ACT OF 2020
For Defaults on Amounts Due from March 1st, 2020 through August 31st, 2020
NOTE: This form is used by a property manager or landlord when a tenant defaults on amounts due under a rental or
lease agreement during the period of March 1st, 2020 through August 31st, 2020, to notify the tenant of the amount of the
delinquent rents and related fees payable within 15 days, and inform the tenant of the protections provided to them under
the COVID-19 Tenant Relief Act of 2020.
DATE: , 20 , at , California.
To Tenant:
Items left blank or unchecked are not applicable.
FACTS:
1. You are a Tenant under a rental or lease agreement
1.1 dated , at , California,
1.2 entered into by , as the Tenant,
1.3 and , as the Landlord,
1.4 regarding real estate referred to as
.
NOTICE:
2. You are in breach of the payment of amounts due under the rental or lease agreement.
3. Within fifteen (15) days after service of this notice you are required to either:
3.1 Pay rent and other amounts now due and unpaid in the Total Amount of . . . . . . . . . . . . . . . . .$
representing rent for the periods of
, 20 to , 20 . . . . . . . Amount $
, 20 to , 20 . . . . . . . Amount $
, 20 to , 20 . . . . . . . Amount $
and amounts due for
� returned check fees of . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . .$
� late charge fees of . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $
� common area maintenance (CAM) of . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
� association assessments of . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
� property taxes of . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
� interest on delinquent rent of . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $
The Total Amount due may be paid in one of the following manners:
a. By personal delivery to (Name)
(Address)
(Phone)
Payment of the Total Amount due will be accepted at the above address during
the hours of to on the following days: .
b. By deposit into account number
at (Financial Institution)
(Address)
c. By the electronic funds transfer previsouly established between Landlord and Tenant.
d.
OR
3.2 Sign and deliver the attached Tenant Declaration of COVID-19-Related Financial Distress (and proof of income if
checked below) within 15 days to Landlord or to avoid
eviction. [See RPI Form 575-4]
4. NOTICE FROM THE STATE OF CALIFORNIA:
If you are unable to pay the amount demanded in this notice, and have decreased income or
increased expenses due to COVID-19, your landlord will not be able to evict you for this missed
payment if you sign and deliver the declaration form included with your notice to your landlord within
15 days, excluding Saturdays, Sundays, and other judicial holidays, but you will still owe this money
to your landlord. If you do not sign and deliver the declaration within this time period, you may lose
the eviction protections available to you. You must return this form to be protected. You should keep
a copy or picture of the signed form for your records.
1.
2.
3.
$
$
$
-------------------------------------------------------------PAGE 1 OF 2 — FORM 575 (COVID-19) -------------------------------------------------
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FORM 575 (COVID-19) 09-20 ©2020 RPI — Realty Publications, Inc., P.O. BOX 5707, RIVERSIDE, CA 92517
Date: , 20
Landlord/Agent: DRE#
Signature:
Address:
Phone: Cell:
You will still owe this money to your landlord and can be sued for the money, but you cannot be
evicted from your home if you comply with these requirements. You should keep careful track of what
you have paid and any amount you still owe to protect your rights and avoid future disputes. Failure
to respond to this notice may result in an unlawful detainer action (eviction) being filed against you.
For information about legal resources that may be available to you, visit lawhelpca.org.
5. Proof of income on file with your landlord indicates that your household makes at least
130 percent of the median income for the county where the rental property is located,
as published by the Department of Housing and Community Development in the Official
State Income Limits for 2020. As a result, if you claim that you are unable to pay the amount
demanded by this notice because you have suffered COVID-19-related financial distress,
you are required to submit to your landlord documentation supporting your claim together with
the completed declaration of COVID-19-related financial distress provided with this notice.
If you fail to submit this documentation together with your declaration of COVID-19-related financial
distress, and you do not either pay the amount demanded in this notice or deliver possession of the
premises back to your landlord as required by this notice, you will not be covered by the eviction
protections enacted by the California Legislature as a result of the COVID-19 pandemic, and your
landlord can begin eviction proceedings against you as soon as this 15-day notice expires.
6. If you fail to pay the Total Amount due or return the Tenant Declaration of COVID-19-Related Financial Distress (and
proof of income if checked above) within fifteen (15) days, legal proceedings will be initiated against you to regain
possession of the premises and to recover the amounts owed, treble damages, costs and attorney fees. [See RPI Form
575-4]
7. The Landlord hereby elects to declare a forfeiture of your Right to Possession if you fail to pay the Total Amount
demanded above or fail to return the Tenant Declaration of COVID-19-Related Financial Distress (and proof of income
if checked above).
7.1 Landlord reserves the right to pursue collection of any future loss of rent allowed by Civil Code §1951.2.
8. State law permits former Tenants to reclaim abandoned personal property left at the former address of the Tenant, subject
to certain conditions. You may or may not be able to reclaim property without incurring additional costs, depending on
the cost of storing the property and the length of time before it is reclaimed. In general, these costs will be lower the
sooner you contact your former Landlord after being notified that property belonging to you was left behind after you
moved out.
-------------------------------------------------------------PAGE 2 OF 2 — FORM 575 (COVID-19) -------------------------------------------------
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NOTICE FROM THE STATE OF CALIFORNIA:
The California Legislature has enacted the COVID-19 Tenant Relief Act of 2020 which protects renters
who have experienced COVID-19-related financial distress from being evicted for failing to make rental
payments due between March 1, 2020, and January 31, 2021.
“COVID-19-related financial distress” means any of the following:
1. Loss of income caused by the COVID-19 pandemic.
2. Increased out-of-pocket expenses directly related to performing essential work during the COVID-19
pandemic.
3. Increased expenses directly related to the health impact of the COVID-19 pandemic.
4. Childcare responsibilities or responsibilities to care for an elderly, disabled, or sick family member
directly related to the COVID-19 pandemic that limit your ability to earn income.
5. Increased costs for childcare or attending to an elderly, disabled, or sick family member directly
related to the COVID-19 pandemic.
6. Other circumstances related to the COVID-19 pandemic that have reduced your income or increased
your expenses.
This law gives you the following protections:
1. If you failed to make rental payments due between March 1, 2020, and August 31, 2020, because
you had decreased income or increased expenses due to the COVID-19 pandemic, as described
above, you cannot be evicted based on this nonpayment.
2. If you are unable to pay rental payments that come due between September 1, 2020, and January
31, 2021, because of decreased income or increased expenses due to the COVID-19 pandemic,
as described above, you cannot be evicted if you pay 25 percent of the rental payments missed
during that time period on or before January 31, 2021.
You must provide, to your landlord, a declaration under penalty of perjury of your COVID-19-related
financial distress attesting to the decreased income or increased expenses due to the COVID-19
pandemic to be protected by the eviction limitations described above. Before your landlord can seek to
evict you for failing to make a payment that came due between March 1, 2020, and January 31, 2021,
your landlord will be required to give you a 15-day notice that informs you of the amounts owed and
includes a blank declaration form you can use to comply with this requirement.
If your landlord has proof of income on file which indicates that your household makes at least 130
percent of the median income for the county where the rental property is located, as published by the
Department of Housing and Community Development in the Official State Income Limits for 2020, your
landlord may also require you to provide documentation which shows that you have experienced a
decrease in income or increase in expenses due to the COVID-19 pandemic. Your landlord must tell
you in the 15-day notice whether your landlord is requiring that documentation. Any form of objectively
verifiable documentation that demonstrates the financial impact you have experienced is sufficient,
including a letter from your employer, an unemployment insurance record, or medical bills, and may be
provided to satisfy the documentation requirement.
It is very important you do not ignore a 15-day notice to pay rent or quit or a notice to perform covenants
or quit from your landlord. If you are served with a 15-day notice and do not provide the declaration
form to your landlord before the 15-day notice expires, you could be evicted. You could also be evicted
beginning February 1, 2021, if you owe rental payments due between September 1, 2020, and January
31, 2021, and you do not pay an amount equal to at least 25 percent of the payments missed for that
time period.
For information about legal resources that may be available to you, visit lawhelpca.org.
For information, resources, and support visit www.LandlordTenant.dre.ca.gov.
TENANT DECLARATION OF COVID-19-RELATED FINANCIAL DISTRESS
Code of Civil Procedure Section 1179.02(d)
DATE: , 20 , at , California.
To Landlord:
Items left blank or unchecked are not applicable.
FACTS:
1. I am a Tenant under a rental or lease agreement
1.1 dated , at , California,
1.2 entered into by , as the Tenant,
1.3 and , as the Landlord,
1.4 regarding real estate referred to as
.
2. I am currently unable to pay my rent or other financial obligations under the lease in full because of one or more of the
following:
2.1 Loss of income caused by the COVID-19 pandemic.
2.2 Increased out-of-pocket expenses directly related to performing essential work during the COVID-19 pandemic.
2.3 Increased expenses directly related to health impacts of the COVID-19 pandemic.
2.4 Childcare responsibilities or responsibilities to care for an elderly, disabled, or sick family member directly related
to the COVID-19 pandemic that limit my ability to earn income.
2.5 Increased costs for childcare or attending to an elderly, disabled, or sick family member directly related to the
COVID-19 pandemic.
2.6 Other circumstances related to the COVID-19 pandemic that have reduced my income or increased my expenses.
Any public assistance, including unemployment insurance, pandemic unemployment assistance, state disability insurance
(SDI), or paid family leave, that I have received since the start of the COVID-19 pandemic does not fully make up for my loss
of income and/or increased expenses.
For information about legal resources that may be available to you, visit https://lawhelpca.org/.
For information, resources, and support visit www.LandlordTenant.dre.ca.gov.
1.
NOTE: This form is used by a tenant under a rental or lease agreement when they have defaulted in rental payments
during the period of March 1st, 2020 through January 31st, 2020, to notify the landlord the default was the result of COVID-
19-related financial distress and obtain eviction protection under the COVID-19 Tenant Relief Act of 2020.
Signed under penalty of perjury under the laws of the State of California.
Date: , 20
Signature:
Signature:
FORM 575-4 (COVID-19) 09-20 ©2020 RPI — Realty Publications, Inc., P.O. BOX 5707, RIVERSIDE, CA 92517
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