Tenant Petition For Individual Rent Adjustment (Ira) 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. T- ____________
TENANT PETITION FOR INDIVIDUAL RENT ADJUSTMENT
1
Property Address:
Unit No.
.
__________________________________________________
___________
Zip ___________ No. of Bedrooms ________
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.
Grounds for Petition:
Check the reason(s) for filing this petition in the spaces below AND complete the corresponding
Schedule(s). Check all grounds that apply; you will be precluded from obtaining a rent ceiling
reduction on additional grounds through the hearing date. Provide supporting information as
indicated in the schedules. References to regulations are to the Board’s Regulations.
( )
1. Illegally High Rent (Includes Unrefunded Security Deposit) (Regulation 1271)....…….......Schedule A
( )
2. Unrefunded Security Deposit Interest (Regulation 702)..............................................…..….Schedule B
( )
3. Decrease in Space/Services; Substantial Deterioration; Failure to Provide Adequate Services;
Failure to Comply with Codes or the Warranty of Habitability (Regulation 1269).….……..Schedule C
( )
4. Reduction in Number of Tenants Allowed (Regulation 1270).....................................…..….Schedule D
...............................................................
( )
5. Other........
..........………..............……...Attach explanation.
3.
Tenant Information (required):
Dates of Occupancy
Name (Print)
Daytime Phone
Start
End
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.
J:\HEARFRMS\TENANTPKG.doc
1
10/28/05
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