Request for Rental Adjustment

Has the tenant been provided with a 60-90-day notice of rent increase and/or utility responsibility change?

Yes
No

If no, please delay your request for an increase until you have provided the tenant with required notice.

What date was the tenant notified?

What is the effective date of the rental increase?

Please use the date that was provided in the notice to the tenant.

Owner Information:

Owner First Name*

Last Name*

Title*

Owner
Agent
Manager

Street Number*

Example: 1001

Street Name*

Example: Main St

City*

State*

Zipcode*

Phone*

Email*

Requested Rent*

Current Rent*

Vendor Number

Client Information:

Client First Name*

Last Name*

Client Number

Street Number*

Example: 1001

Street Name*

Example: Main St

City*

State*

Zipcode*

Phone*

1. Building Type*

Square Footage*

Year Built*

Number of Bedrooms*

Number of Bathrooms*

2. Please check all amenities that apply*

AC Unit Type:*

Central Air
Window Unit

Heating Unit Type:*

Central
Wall Unit

How Many Garage Units?

How Many Covered Spaces?

3. Are you requesting a change in Utilities?*

Yes
No

Heating Fuel Type*

Natural Gas
Oil
Electric

Heating Paid By:*

Tenant
Owner

Cooking Fuel Type*

Natural Gas
Oil
Electric

Cooking Paid By:*

Tenant
Owner

Water Heating Fuel Type*

Natural Gas
Oil
Electric

Water Heating Paid By:*

Tenant
Owner

Other Electric Paid By:*

Tenant
Owner

Water Paid By:*

Tenant
Owner

Sewer Paid By:*

Tenant
Owner

Trash Collection Provided By:*

Tenant
Owner

Trash Collection Paid By:*

Tenant
Owner

Refrigerator Provided By:*

Tenant
Owner

Refrigerator Paid By:*

Tenant
Owner

Range Provided By:*

Tenant
Owner

Range Paid By:*

Tenant
Owner

Unassisted Units:

If complex has two or more units of same bedroom/bath size, provide comparable data below on unassisted units that are in the same complex for units leased within 60 days of this request.

Are all units assisted?

Yes
No

Individually Owned?

Yes
No

1. Address of Unit (Include Apt #)

Rent Amount $

Number of Bedroom(s)/Bath(s)

Date Rented

2. Address of Unit (Include Apt #)

Rent Amount $

Number of Bedroom(s)/Bath(s)

Date Rented

3. Address of Unit (Include Apt #)

Rent Amount $

Number of Bedroom(s)/Bath(s)

Date Rented

As the Owner, I am aware that:*

I am not permitted to reside in the assisted unit while I am receiving Housing Assistance Payments. Are you the parent, child, grandparent, sister, brother, stepparent or stepchild of any member of the tenant family?

Yes
No

Acknowledgement*

By ticking this box and clicking "Submit" you confirm that all information entered in this form is accurate and valid.

Email

This field is for validation purposes and should be left unchanged.

Request for Rental Adjustment

Request for Rental Rate Adjustment

Owner Information:

Client Information:

Unassisted Units:

DHA SERVICES HQ

HOUSING CHOICE VOUCHER SERVICES

HOUSING CHOICE VOUCHER SERVICES