Request For Relocation Payment From Property Owner Form printable pdf download

City of Berkeley

REQUEST FOR RELOCATION PAYMENT FROM PROPERTY OWNER

For Temporary Relocations Lasting 30 Days or Longer

Tenant Name: _______________________________________

Date: _____________

Unit Address: _____________________________________

Bedroom Size: _________

Estimated date of Move-Out: __________

Estimated period of relocation: ___________

INITIAL RELOCATION PAYMENT CALCULATION

Relocation Payment

Calculation

Amount

$400

Dislocation Allowance (fixed payment)

$400

Moving Costs, if applicable:

Include either:

 Fixed payment: $ 300

Either the fixed payment of $300, or reimbursement

of actual costs. If requesting reimbursement,

OR:

include estimate from a licensed moving company

 Estimate of actual cost

(and not to exceed rates set by Federal Highway

$____________

$________

Administration).

Storage Costs, if applicable:

Include either: $0 if not

applicable or:

Either the fixed payment of $200 without receipts,

 Fixed payment: $ 200 OR:

or reimbursement of actual expenses with receipts.

If requesting reimbursement, include estimate of

 Actual cost per month:

cost provided by storage facility.

$_________

$________

Rent Differential Payment:

(A) Current rent: $__________

(B) New rent:

$__________

If the monthly rent for your replacement housing is

higher than your current rent, then you qualify for a

rent differential payment that covers the difference,

below):

$__________

up to a ceiling based on the Rent Ceiling chart

Monthly Rent Differential

below for the bedroom size of your unit.

$_________

Payment:

$__________

To calculate the payment, take the lesser of the

Note: If period of relocation

rent for your replacement housing and the

exceeds 90 days, the initial

maximum rent from the chart below based on the

rent differential payment is for

bedroom size of your unit, and subtract your current

the first 90 days: monthly

rent. This amount will be your monthly rent

amount x 3 = $___________

differential payment.

Maximum Rent Levels for Replacement Units for 2014

Studio: $1100

1 BR: $1460

2 BR: $2046

3 BR: $2895

INITIAL RELOCATION PAYMENT:

[Includes: 1) Dislocation Allowance, 2) Moving Costs, 3) fixed payment or one month

$________

storage cost, 4) Rent Differential for first month or for initial 90 days.]

Tenant’s Signature: __________________________________ Date: _______________

Contact Information: Phone: ___________________ Email: ________________________

Mailing Address: ___________________________________________________________

Request For Relocation Payment From Property Owner Form

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