660105 EM 7.24.19
Landlord Incentive Program HCV Claim Form
This claim form is provided for reimbursement subject to availability of funds by jurisdiction through the
Landlord Incentive Program. Submit this form and documentation within three months of vacancy date.
Tenant Information
Tenant Name: __________________________________________________________________________
SSN: ____________________________________ Program: ___________________________________
Address of Unit: ________________________________________________________________________
Move In Date: ______________ Vacate Date: ____________________
Landlord / Unit Information
Landlord Name: ____________________________________________________Phone: ________________
Monthly Rent: _____________________ Security Deposit: ________________________
Circumstances of Claim – Claims can be requested in the following circumstances.
Lease termination with cause.
Tenant vacated unit with damages.
Tenant vacated unit owing back rent.
Legal fees associated with
termination for lease violations and lease compliance
Expenses Included in Claim – The following expenses are eligible, up to a $2,500 maximum, to the extent that
actual expenses exceed the security deposit.
Damages: Damages caused by the tenant that exceed the security deposit and for which the tenant has not
otherwise reimbursed the landlord. Normal ‘wear and tear’ is not an allowable expense.
Description of damages: _______________________________________________________________
Full amount of tenant caused damages (do not deduct security deposit): _________________________
Attach the following:
Complete itemized list of damages with paid receipts attached.
Evidence that tenant caused damages (dated photographs of move in / move out condition, move in /
move out inspections, etc.)
Copy of letter mailed to tenant requesting payment for damages (letter must be mailed to tenant at
last known address).
Unpaid Rent: Unpaid rent balances remaining after the tenant vacates the unit. The maximum
claim is 4 months rent.
660105 EM 7.24.19
Enter dates for unpaid rent: _____________________________________________________________
Full amount of unpaid rent (do not deduct security deposit): _________________________
Attach the following:
Evidence that tenant did not pay rent (statement showing amount and period for which rent is
unpaid, showing amounts charged, amounts received from tenant and / or from rental assistance
program, and balance owed).
Copy of letter mailed to tenant requesting payment of unpaid rent (letter must be mailed to tenant at
last known address and owner must include proof of mailing certificate from post office).
Vacancy Loss: - Vacancy loss in the event of vacancy due to lease violations. The maximum claim is 100%
of the contract rent for the first 30 days following the vacancy, and 80% of the contract rent for the
following 30 days, if the unit remains vacant.
Enter dates for vacancy loss: ______________________________________________________________
Did you take all feasible actions to fill vacancy? _____ Yes _____ No
Did you reject any eligible applicants without good cause? _____ Yes _____ No
Legal Fees: - Legal fees associated for terminations due to lease violations.
Full amount of legal fees (do not deduct security deposit): _________________________
Attach the following:
Paid invoice from legal counsel, referencing the tenant / unit listed above.
By signing this form, I certify that all of the information provided above is true, correct, and complete to the best
of my knowledge, and will be relied upon for purposes of determining eligibility for the landlord incentive
program claim reimbursement. This is only good for unreimbursed expenses; if I am reimbursed by an insurance
company, the tenant or any other source, I will reimburse the Housing Authority. Any misstatement or false
statement may result in denial / loss of reimbursement. In addition, I understand that any misrepresentation in my
statements may be considered to be fraud. Warning: Title 18 Section 1001 of the United States Code states that
any person would be guilty of a felony for knowingly and willingly making false or fraudulent statements to any
Department or Agency of the United States.
Print Name Signature Date