Santa Cruz Housing Authority - Request For Rent Increase/change Of Terms Please
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12931 Mission Street, Santa Cruz CA 95060-5709
Ph: (831) 454-9455, Fax: (831) 469-3712
Request for Rent Increase/Change of Terms
Please complete this form and submit it on line, or mail to the Housing Authority at the above address. The
Housing Authority will review your request and determine if an increase/change can be granted. Please allow 60
days for a review to take place.
O wner Information:
U
Name:
___________________________________________________________________________
Mailing Address:
___________________________________________________________________________
Phone Number:
____________________
E-Mail Address:
________________________________
Tenant Name:
___________________________________________________________________________
Tenant Address:
___________________________________________________________________________
No. of Bedrooms:
___
Current Rent:
______
Proposed Rent:
______
Effective date:
_________
If you are requesting a change in rent please answer this question as well: Do you provide any other special
services to your tenant? (Landscaping, housekeeping, etc.)
Yes
No
If yes, please explain: ________________________________________________________________________
C hange In Term:
U
What is the term of the lease?
1 Year
Month to Month
Other: ________________________
C hange In Utility Responsibility:
U
If you want to modify who is responsible for utilities please complete:
Who pays for each of the following utilities?
Who will provide the following appliances?
Electricity
Tenant
Owner
Range
Tenant
Owner
Gas
Tenant
Owner
Refrigerator
Tenant
Owner
Garbage
Tenant
Owner
Sewer
Tenant
Owner
What is the energy source?
Water
Tenant
Owner
Cooking
Gas
Electric
Propane
Hot Water
Tenant
Owner
Heating
Gas
Electric
Propane
Hot Water
Gas
Electric
Propane
I hereby certify that I am the owner or the duly authorized representative of the property for which this
rent increase request is being submitted and that entering my name below is the equivalent to my
handwritten signature. Landlord certifies that has issued 60 (sixty) day notice of this rent increase to the
above tenant.
Name: _________________________________
Date: _______________________
Print Form
Submit by E-mail
550125 MF 11/05/2014
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