Tenant Petition For Individual Rent Adjustment (Ira) Form Page 3
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44.
Landlord: List the owner(s) of the building and the person to whom you pay your rent.
Name ___________________________________ Daytime Phone ___________________________
Address ____________________________ City ______________ State ______ Zip ____________
Name ___________________________________ Daytime Phone ___________________________
Address ____________________________ City _______________ State _______ Zip __________
5.
Representative: Person or organization authorized to represent you, if any:
Name ___________________________________ Daytime Phone ___________________________
Address ____________________________ City ______________ State ______ Zip ____________
6.
Consolidation: If another petition was recently filed for the same property, and you know the petition
number or unit designation, please provide that information.
___________________________________
7.
Certification: I declare under penalty of perjury of the laws of the State of California that the
information in this petition, and in all schedules, attachments and forms, is true and correct to the best of
my knowledge and belief.
Signature
Date
_________________________________________________
____________________
Printed Name
_______________________________________________
Signature
Date
_________________________________________________
____________________
Printed Name
_______________________________________________
Signature
Date
_________________________________________________
____________________
Printed Name
_______________________________________________
Signature
Date
_________________________________________________
____________________
Printed Name
_______________________________________________
NOTE: All signatures must be original and all petitioning tenants must sign the Certification.
J:\HEARFRMS\TENANTPKG.doc
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10/28/05
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