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.
Certification
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
