Dispute Resolution Request Form

Community Development Agency

Fields marked with an asterisk are required fields. A Marin County representative will receive your submission and you will receive an emailed copy as well. So please double-check the email address you've entered to ensure you receive your copy.

Current Rental Information
*
Tenant's Contact Information
*
*
*
*
i.e. (555) 555-5555
*
Tenant Representative's Contact Information (if any)

If a tenant is unable to participate in mediation, they may designate a representative to negotiate on their behalf.

i.e. (555) 555-5555
Landlord's Contact Information
*
*
*
*
i.e. (555) 555-5555
*
Landlord's Representative's Contact Information (if any)

If a landlord is unable to participate in mediation, they may designate a representative to negotiate on their behalf.

i.e. (555) 555-5555
General Rental History - Help us get a sense of your situation.
ie MM/YY
Notices to Tenant

In the past 12 months the tenant has been or will be issued the following notices of monthly rent increase(s):

Month/Day/Year
Month/Day/Year
Month/Day/Year
Month/Day/Year
Date of notice of the most recent rent increase.
Are the rent payments current for the rental unit?

(e.g. “rent has not been paid this month,” or “rent has not been paid for 3 months,” etc. and provide rationale). If rent is being withheld due to alleged habitability violations, please identify those conditions here.
Have you previously participated in mediation for this rental or landlord/tenant?

Property Description
Do you wish to consolidate this request for mediation with another request?

Attach a list of any other requests for mediation that you think should be heard concurrently with this request and contact information for the parties.
Description of Activities Requested for Mandatory Mediation
I am a tenant who has:

In your understanding, is the increase more than 5%?

You believe a rent increase and/or reduction in housing services* results in a cumulative rent increase of more than 5% from 12 months prior.
I am a landlord who intends:

- Increase my tenant’s rent by more than 5% of the monthly rent in the past 12 months.
- Reduce housing services that are valued at more than 5% of my tenant’s monthly rent in the past 12 months.
Signature
By signing my name below, I declare under penalty of perjury that the foregoing is true and correct and that all documents attached to my request are true copies of the originals.