Owner Rent Increase Request Owner InformationOwner Name* First Last Mailing Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone Number* Email Address* Tenant/Unit InformationName* First Last Tenant/Unit Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Number of Bedrooms* Current Rent* Proposed Rent* Effective Date*Warning: Requests not received 60 days prior to the effective date are prohibited by program rules. However, please proceed with submission of this form. You will be contacted to clarify the effective date. MM slash DD slash YYYY What is the term of release renewal?* One Year Month-to-Month Other Other term of release renewal: Are there any changes in the provisions of the lease?* Yes No Please attach a copy of any renewal notice Drop files here or Select files Max. file size: 512 MB. Please attach a copy of the revised lease with any renewal notice Drop files here or Select files Max. file size: 512 MB. Is the term of the lease being changed? Yes No Since the terms of the lease are changing, a new tenancy must be approved and a new HAP contract signed. I understand Is responsibility for any utilities changing? Yes No Since responsibility for utilities are changing, a new tenancy must be approved and new HAP contract signed. I understand Reminder and CommentsReminder: The rent must be determined to be reasonable. HRHA will compare the requested rent to going rents of similar, unassisted rental units in the same market area. If your request cannot be approved, we will contact you promptly. Otherwise, the new rent will be reflected in a revised rent letter containing updated tenant and HRHA portions. If you have any comments or questions feel free to leave them below. CertificationI 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 all information provided is true and correct to the best of my knowledge. I certify that I have given a 60-day notice of this rent increase to the tenant. I certify that I am maintaining the unit in accordance with housing quality standards. I certify that the rent to owner does not exceed rents charged for rental of comparable unassisted units in the premises. I certify that except for the specified rent to owner amount, I have not received and will not receive any payments or other consideration from the family for the rent of the unit during the contract term. I understand that clicking this checkbox is the equivalent to my handwritten signature. I understand and certify
