Covid-19 Deferral Form

Covid-19 Rent Deferral Request (July 2021)

Tenant Information Collection:
Name*
First Last
Phone Number*
Email Address*
Property Address*

Please enter the address of the property you're applying for.
Unit Number*

Please enter the unit number of the property you're applying for. (If applicable)
Names of ALL people residing in the unit
Monthly Rent*
Please enter a number from 0 to 8000.
Security Deposit
Please enter a number from 0 to 8000.
Lease Start Date
MM slash DD slash YYYY
Lease Termination Date
MM slash DD slash YYYY
IMPORTANT NOTICE: Tenants are still obligated to pay their rent balance in full. However, during the emergency period (through April 30, 2020), tenants that can substantiate one or more of the outlined circumstances below due to the financial impacts related to COVID-19, will not be evicted for failure to pay their monthly rent in full during this time period. Tenants will have up to twelve (12) months following the expiration of the local emergency to repay all of the back rent due. Failure to pay the rent within the time period provided may subject you to legal proceedings and other remedies available to the landlord in seeking unpaid rent, including eviction. (Your monthly rent is not being reduced, waived or offset. The eviction moratorium was drafted to allow tenants experiencing negative financial impacts related to the COVID-19 emergency, additional time to pay their monthly rental obligations over a 12-month period. )
Check Boxes: I/We hereby request deferment of Rent due to the following reason(s): (Check all boxes that apply)
- Loss of income due to work place closure or reduced hours or services due to COVID-19
- Child care expenditures or inability to work due to school closures
- Health care expenditures stemming from COVID-19 infection of the tenant or a member of the tenant’s household who is ill with COVID-19
- Reasonable expenditures stemming from government ordered emergency measures
Explanation
Lease Upload
Max. file size: 15 MB.
Please provide documentation that supports your hardship claim, such as a letter from your employer.
Drop files here or

Max. file size: 15 MB.
A copy of the Ordinance outlining the protections of this article is available for viewing here: Los Angeles Municipal Code
By checking this box, you hereby acknowledge having read or obtained a copy of the Ordinance for future reference through the link provided above and further agree to receive a copy of this Ordinance as a PDF via the email address provided herein upon the completion of this form.*
- I acknowledge
Please also mail me a physical copy of the Ordinance to the address provided above or the address provided below:
- Mail me a physical copy
- Do not mail me a physical copy
Mailing Address (if answered yes above)
Upon receipt of all qualifying documentation submitted by the tenant(s), an LBPM representative will review the information for compliance with the criteria outlined herein. Tenants will be notified within 7 business days of the decision based on the documentation provided. If additional information is required, a management representative will be in contact with you directly. Tenants experiencing hardship due to the COVID-19 emergency will have the ability to set up a payment plan to repay any missed rent over a period of time not to exceed twelve (12) months. We appreciate your patience and cooperation during this extremely trying and difficult time. Thank you.
Requested Payment Plan Options:
- Deferment of April Rent
Repayment Period
Your new monthly rent for the repayment period, which includes a prorated portion of your deferred rent based upon the number of months selected for your repayment plan:
By submitting this form, you are providing notice that you have been impacted by one or more of the circumstances related to the COVID-19 Emergency as described herein. Accordingly, in order to temporarily delay any potential eviction proceedings against you for non-payment of rent, you are obligated to provide specific, verifiable and supporting documentation for review which demonstrates how your specific issues related to the COVID-19 Emergency are impacting your ability to pay rent. Please note that without sufficient supporting documentation, your request may be denied. Furthermore, you are hereby acknowledging this request for a partial or full deferment of your next monthly rent payment is solely for purposes relating to the COVID-19 Emergency; and for no other reason including the habitability or any other general conditions of your dwelling at this time.

Covid-19 Deferral Form

Covid-19 Rent Deferral Request (July 2021)

Tenant Information Collection: