Landlord Risk Mitigation Fund Application

Landlord Risk Mitigation Fund Application
Overview and Instructions
Before a claim is filed, landlords must have contacted the tenant directly and followed the procedures used for all tenants. If issues continue, contact the tenant’s supportive service worker as soon as possible for assistance in resolving the issue. If the tenant defaults on their lease or damages the property in excess of the damage deposit, contact the supportive service worker and complete this claim packet.

Please review the claim instructions and information on the next page before completing and submitting the claim for review. Consult the tenant’s service provider and/or LRFM program staff with questions or clarifications. The LRMF Advisory Board reviews claims once a month, and the claim must be submitted on/by the first business day of the month. The LRMF Advisory Board will not review claims until the claim is completed with the required accompanying material. Claims must be submitted to LRMF within 60 days from the time the damage or loss occurred. (An exception to this requirement is pending insurance determination that would prevent the claim form from being complete. In these instances, LRMF must be notified of the intent to file a claim within 60 days of the occurrence.) Payments will be issued within 30 business days of the completed application submission and advisory board approval.

Qualifying Expenses
The Landlord Risk Mitigation Fund will reimburse up to $3,000 for physical and operational losses for up to two years after move-in. The fund could cover the following expenses:
- Damages caused by the tenant, beyond normal wear and tear to the unit, that exceed the security deposit.
- Up to two months of rent non-payment, if the tenant does not vacate the apartment in good standing.
- Court costs and attorney fees were necessary, up to $500, to terminate a tenancy and remove a participant for nonpayment of rent or other serious and repeated violations of the lease in accordance with state law. (Landlords seeking reimbursement must provide evidence that they took reasonable steps to avoid eviction and that a legal proceeding was necessary to avoid greater financial hardship.)

Property Information
Property Name*
Property Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Tenant's Name*

First NameLast Name
Primary Contact*

First NameLast Name
Contact's Email Address*
example@example.com
Contact's Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Associated Support Agency*
Additional Information

Claim Request Calculations

All reported costs must be supported by submitted invoices and receipts.
Total Cost of Parts and Materials (Enter 0 if No Cost)*
Total Cost of Labor (Enter 0 if No Cost)*
Total Operational Costs (Enter 0 if No Cost)*
Total Unpaid Rent Costs*
Total Costs Reported
Total Deposit Received*
Costs Covered by Insurance or Reimbursements*
Total Available Reimbursements and Deposits
Total Costs Less Reimbursements and Deposits

Completing Submission
Has the Service Provider been contacted by the Landlord?*

YesNo
Is the Service Provider participating in the resolution of the issues related to the claim?*

YesNo
Are you legally evicting the tenant?*

YesNo
I acknowledge that this claim is accurate and truthfully reports my costs and reimbursements. I also acknowledge that I understand that this claim will not be processed until supporting invoices, receipts, etc., have been submitted.*

I Acknowledge
My Name*

First NameLast Name
Signature*
Date*

MonthDayYear
Date
Should be Empty:

Overview and Instructions