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Back Rent Subsidy Form
 

Back Rent Subsidy for Housing Providers

~ Survey ~

The City of Beverly Hills recognizes the enormous impacts that the COVID-19 pandemic has had on all the City's residents, including housing providers. In recognition of those impacts, the City is in the process of creating a subsidy program for housing providers who have suffered financial losses due to unpaid back rent from current and former tenants.

**Failure to complete the survey will cause you to be ineligible for any initial round of funding distributed by the City.**
In order to be considered for the first round of payments from this subsidy program, you must fill out the survey below.

Please answer the following questions as completely and accurately as possible.

~ Contact Information ~

Housing Provider Name (Individual or Corporation):
Housing Provider Address:
City:
State:
Zip:
Phone:
Email:
   

~ Property Survey ~

Please list the address of every property that you own, including those outside the City of Beverly Hills
Address:
City:
Zip:
 
Is this a Single-Family Home?   

Address:
City:
Zip:
 
Is this a Single-Family Home?   

Address:
City:
Zip:
 
Is this a Single-Family Home?   

Do you own more than 3 properties?  
 
Please provide the number of units that you own as a total sum of all your properties, including those outside of the City of Beverly Hills.

   

~ Rent Owed to Landlord ~

Please list the address and amount due for every unit that you own that is still delinquent on back rent.  Exclude any back rent that is pending payment through a state or local program, or that has already been paid by such a program.  
Address:
 City:
 
Zip:
Back rent due:
Did the tenant vacate the unit?  
If yes, did you enter a settlement agreement with the tenant?   

Is the tenant delinquent on the settlement agreement?



Address:
City:
Zip:
Back rent due: 
Did the tenant vacate the unit? 
If yes, did you enter a settlement agreement with the tenant? 
Is the tenant delinquent on the settlement agreement?

Address:
City 
Zip
Back rent due: 
Did the tenant vacate the unit? 
If yes, did you enter a settlement agreement with the tenant? 
Is the tenant delinquent on the settlement agreement?

Address
City 
Zip
Back rent due: 
Did the tenant vacate the unit? 
If yes, did you enter a settlement agreement with the tenant? 
Is the tenant delinquent on the settlement agreement? 

Address
City 
Zip
Back rent due: 
Did the tenant vacate the unit? 
If yes, did you enter a settlement agreement with the tenant? 
Is the tenant delinquent on the settlement agreement? 

Address
City 
Zip
Back rent due: 
Did the tenant vacate the unit? 
If yes, did you enter a settlement agreement with the tenant?
Is the tenant delinquent on the settlement agreement? 

Address
City 
Zip
Back rent due:
Did the tenant vacate the unit? 
If yes, did you enter a settlement agreement with the tenant? 
Is the tenant delinquent on the settlement agreement? 

Address
City 
Zip
Back rent due
Did the tenant vacate the unit? 
If yes, did you enter a settlement agreement with the tenant? 
Is the tenant delinquent on the settlement agreement?

How much rent is owed as a total sum for all delinquent units?  
 
 
Thank you for your interest.  We will notify you of the status of the Housing Assistance Program as soon as we are able.  If you have any questions or concerns reltated to the Housing Assistance Program, please reach out to the Rent Stabilization Ordinance Division at 310-285-1031 or by email: bhrent@beverlyhills.org  
 
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    Beverly Hills, CA 90210
  •  
  • (310) 285-1000
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  • Friday 8:00AM-5:00PM

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