Fillable Notice to Landlord of Inability to Pay Rent (County of Los Angeles / Internal Services Department)

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Notice to Landlord of Inability to Pay Rent (County of Los Angeles / Internal Services Department)

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The following template can be used to provide your landlord(s) with notice of your inability to pay rent due
to circumstances related to COVID-19. You should not use this template if your city has its own
moratorium. Please visit rent.lacounty.gov or call us at 833-223-7368 to find out if your city is covered.
Additionally, if you are interested in working out a payment plan, you can contact us for information about
our free mediation services.
As a tenant you are required to provide notice to your landlord no later than seven (7) days after the date
that the rent was due, unless extenuating circumstances exist, that you are unable to pay some or all of
your rent.
Instructions:
on
address date
You may wish to submit documents to support your claim. Some examples include, but are not limited to:
paycheck stubs from before and after the COVID-19 pandemic, a letter from your employer of reduced
hours or layoff due to COVID-19, bank statements showing your financial situation before and after
the COVID-19 pandemic, a statement of diagnosis of COVID-19, or any other documents that verify your
financial loss is related to COVID-19.
on
1. Fill out the template completely.
2. Provide a copy of the template to your landlord no later than seven (7) days after your rent is
due.
a. You can provide this notice in several ways. Please indicate the method in which you
provided notice to your landlord(s) and save it for your records. The Los Angeles County
Department of Consumer and Business Affairs (DCBA) recommends providing notice either
by email or certified mail.
address
date
Certified mail sent to
First Class mail sent
to Other (specify):
on
method
date
date
NOTE: Commercial tenants with more than 9 employees must provide documentation to support their claim.
This temporary moratorium does not provide a waiver of rent. It simply provides you with more time to pay
any past due rent. You will have twelve (12) months following the end of the moratorium period to
pay your landlord any past rent due. Please note that no late fees or interest charges can be accrued during the
moratorium. Additionally, tenants and landlords are encouraged to work out a payment plan during or after
the moratorium. DCBA recommends that you make partial rent payments if you can afford to do so.
Disclaimer: The information provided by DCBA in this document is for informational purposes only. DCBA does not provide legal advice, and nothing in this
document should be construed as legal advice. All information is provided in good faith, however DCBA makes no representation or warranty of any kind,
express or implied, regarding the accuracy, adequacy, validity, reliability or completeness of any information provided, and is not liable for any errors or
omissions. Should this matter result in an Unlawful Detainer action, you may be required to provide documentation. DCBA strongly recommends you consult with
legal counsel in the event a court summons is served, or any other legal actions is taken. DCBA cannot provide legal advice.
Email sent to
on
email address
Notice to Landlord of
Inability to Pay Rent
Due To COVID-19
Enter date emailed
Enter email address you sent email to
Enter the address mail was sent to
Enter date sent
Enter the address mail was sent to
Enter date mail sent
Clear Form
Please enter the method in which you provided notice (ie. text, phone call, in
person, etc). Please be specific.
Date sent
Date
Dear
Landlord
On March 19, 2020, the Chair of the Los Angeles County Board of Supervisors enacted a temporary eviction
moratorium on residential and commercial evictions in Los Angeles County in response to the Coronavirus
(COVID-19) pandemic. The temporary moratorium imposes a ban on evictions for failure to pay rent due to
financial impacts related to COVID-19 for all residential and commercial tenants in Los Angeles County
impacted by the COVID-19 crisis beginning, March 4, 2020 through May 31, 2020.
From:
until further
This letter is to inform you that I will be unable to pay
notice due to financial impacts related to COVID-19. (Check one):
I understand that my rent is not being waived and that I will have twelve (12) months following the
end of the moratorium period to pay back any amount due.
Thank you for your understanding and cooperation during these unprecedented times.
Regards,
Tenant's Signature
Please note that tenants who are impacted by the COVID-19 pandemic are protected from eviction for
nonpayment per the following:
• Governor Gavin Newsom, Executive Order N-37-20, 03/27/20
• LA County Board of Supervisors, Temporary Eviction Moratorium, 03/19/20
• LA County Board of Supervisors, Rent Freeze on Rent Stabilized Units, 03/31/20
NOTICE TO LANDLORD OF INABILITY
TO PAY RENT DUE TO COVID-19
Suspected or confirmed diagnosis of COVID-19 or caring for myself or someone else such as a
household member suspected or confirmed with COVID-19.
Lay-off, loss of hours, loss of revenue, or other income reduction resulting from business closure or
other economic or employer impacts of COVID-19.
Compliance with a recommendation from the County's Health Officer to stay home, self-quarantine,
or avoid congregation with others during the state of emergency.
Extraordinary out-of-pocket medical expenses related to diagnosis and testing for and/or treatment
of COVID-19.
Child care needs arising from school closures related to COVID-19.
Other (specify):
I will be only able to pay $
per month until further notice.
I have attached supporting documentation to support my claim, as indicated on the next page.
my rent due on
Name of landlord/manager
Enter your name
Street Address
City, State, Zip Code
Enter your reason here
choose one
Date rent is due
Enter amount
you can pay
I have included the following documents as verification of my inability to pay rent caused by
COVID-19. I understand I may not be required to provide documentation, but have enclosed the
following to further support my claim:
A doctor's statement verifying a diagnosis of COVID-19
A letter from my employer stating that I have had a reduction in work hours, experienced a lay
off or termination due to COVID-19
Financial statements from my banking institution demonstrating my financial status before and
after the declaration of the COVID-19 pandemic.
Paycheck stubs demonstrating a loss of income for the periods before and after the
declaration of the COVID-19 pandemic.
Other (specify):
Please note that these documents are to be kept confidential and only used to verify my loss of
income is due to COVID-19
Enter document description and how it demonstrates
finacial loss due to COVID-19
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Notice to Landlord of Inability to Pay Rent (County of Los Angeles Internal Services Department)

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Completed 30 November 2020

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