Housing Choice Voucher Program (Hcvp) Rent Increase Request Form
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1The District of Columbia Housing Authority
Housing Choice Voucher Program (HCVP)
RENT INCREASE REQUEST FORM
(
Incomplete forms will not be processed.)
Landlord Name and Mailing Address
______________________________________________
Phone# _______________________________
__________________________________________________
Email _______________________________
__________________________________________________
Tax I.D. # ____________________________
(Please write legibly)
HCVP PARTICIPANT INFORMATION
Tenant Name: _____________________________________________ No. Bdrms:
_____________________
Unit Address: _____________________________________________
Current Rent: _____________________
Unit # ____________ Washington, D.C. ZIP __________________
Does your lease make provisions for a
Requested Increase Amount: _______________________________
rent increase? Yes
No
PROPERTY INFORMATION
I. BUILDING TYPE: (Check one)
High-rise:
Mid-rise :
Garden:
Townhouse:
Duplex:
Interior Row:
Single Family:
Semi-Detached:
II. AMENITIES PROVIDED BY OWNER: (Check all that apply)
Central A/C:
Window A/C Units:
Carpeting:
Dishwasher:
Garbage disposal:
Washer/Dyer:
Other:
________________________________
IV. AGE: Approximate age of unit? ___________
III. UTILITIES: ( T) Tenant and (O) Owner
Paid by
Paid by(T/0)
Item
Source
(T/0)
Item
Source
Heating
Natural gas
Water heating
Natural gas
Bottle gas
Bottle gas
Oil/Electric
Oil/Electric
Coal/Other
Coal/Other
Cooking
Natural gas
Water
Bottle gas
Sewer
Oil/Electric
Trash
Coal/Other
Range/Micro
Other Electric
Refrigerator
Air Conditioning
Other (specify)
V. MAINTENANCE AND SERVICES: Is on-site maintenance provided?
Yes
No
Are housing services provided?
Yes
No
VI. QUALITY RATING: (Please rate the quality of the unit. Check only one.)
A – Newly constructed or completely renovated within the past 12 months
B – Well maintained and/or partially renovated within the past 12 months
C – Adequate, but some repairs may be needed soon
_______________________________________________
________________________
Landlord/Representative Signature
Date
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Do not write below this point
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APPROVE INCREASE AMOUNT: _____________________ Effective Date: __________________
DECISION CODE: _____________
Census Tract: ____________
(Reference attached Information Sheet)
Current Contract Rent: ____________ Voucher Size: _____________ No. of Bdrms: ____________
Anniversary Date: ______________ Date Requested: _____________ Date Received: ____________
Official Signature: __________________________________________ Date: ____________________
Created 04/2005
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