* Required Field

Notice of Relocation Payment Form

1. Rental Dwelling Unit Information

Street Address*

e.g. 1120 SW 5TH or 5TH AND MAIN

Apartment/Unit #

City*

State*

Zip*

2. Who made the Relocation Payment? (will be point of contact)

Name*

Street Address*

e.g. 1120 SW 5TH or 5TH AND MAIN

Apartment/Unit #

City*

State*

Zip*

Mailing Address *

Apartment/Unit #

City*

State*

Zip*

Primary Phone*

E-mail Address*

3. Ownership Information

Please provide information on the ownership structure of the Dwelling Unit for which you paid a Relocation Assistance Payment.

Select One *

If owned by a business entity, indicate type (example-LLC) and name of entity

4. Payment Trigger

Please provide the basis on which you made the Relocation Assistance Payment.

Select One*

5. Unit Size

Please provide the bedroom count of the unit.

Select One*

Form Certification

I hereby certify that the above information, to the best of my knowledge is true and complete. I understand that I must inform the Portland Housing Bureau immediately and in writing of any changes. I understand that a Landlord that fails to comply with any of the requirements set forth in PCC 30.01.085 shall be liable to the Tenant for an amount up to 3 times the monthly Rent as well as actual damages, Relocation Assistance, reasonable attorney fees and costs.

Electronic Signature *

Date*

The City of Portland, Oregon

Portland Housing Bureau

Solving the unmet housing needs of the people of Portland.

Notice of Relocation Payment Form