Tenant Petition For Rent Withholding For Failure To Register Form Page 2
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4CITY OF BERKELEY
RENT STABILIZATION BOARD
2125 Milvia Street, Berkeley, CA 94704
TEL: (510) 981-7368 (981-RENT) TDD: (510) 981-6903 FAX: (510) 981-4940
E-MAIL: rent@ci.berkeley.ca.us INTERNET:
PETITION NO. RWN - _______________
TENANT PETITION FOR RENT WITHHOLDING FOR FAILURE TO REGISTER
1.
Property Address: __________________________________________________ Zip __________
Is this a single-family home?
Yes ______
No ______ If yes, and your tenancy began on or after
January 1, 1996, contact a Rent Board counselor before filing this petition to determine if the Rent
Board has jurisdiction over your claims.
2.
Tenant Information (required):
Move-in
Amoun
Date Rent
Name (Print)
Unit
Daytime Phone
Date
t
Last Paid
Mailing Address: (If different from the unit address)
___________________________________________________________________________________
NOTE: Your mailing address and any subsequent changes of address will be part of the official
record of the case and a matter of public record.
3.
Landlord: List the property owner(s) and the person to whom you pay your rent, if different.
Name ___________________________________ Daytime Phone ___________________________
Address ____________________________ City ______________ State ______ Zip ____________
Name ___________________________________ Daytime Phone ___________________________
Address ____________________________ City _______________ State _______ Zip __________
4.
Representative: Person or organization authorized to represent you, if any:
Name ___________________________________ Daytime Phone ___________________________
Address ____________________________ City ______________ State ______ Zip ____________
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J:\HEARFRMS\ RWNPET.doc
10/28/05
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