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RPSS Support Services
Mediation Request Form
Please fill out the form below to request mediation services. Make sure to provide accurate and detailed information about the property, tenant, and nature of the conflict. Once your request is submitted, our team will review the information and reach out to you to discuss the next steps.
Building Address
(Required)
Include the unit number
Tenant Name
(Required)
Enter Full Name
Subsidy
(Required)
TLS
SSVF
HACLA
LACDA
VASH
LB/OC
CONFLICT DETAILS
Service Request
(Required)
Risk Mitigation Funds Requested
Mediation Services
Please pick one.
Lease Violation
(Required)
Rent Arrears
Vacancy Loss
Property Damage
Disturbance
Threat of Eviction
Other – please describe
Conflict Summary
(Required)
Provide a detail account of your request.
Desired Outcome
(Required)
What amount are you requesting to utilize from the Risk Mitigation Funds?
(Required)
Reminder: Utilities, amenities, late fees, legal fees, etc. are not eligible for Risk Mitigation Funds.
REQUIRED DOCUMENTATION
Upload Limit Notice: Please note that this form only allows 1 file upload per field. If you have multiple documents, combine them into a single file before uploading. If multiple files are uploaded in the same field, only the first file will be received and processed.
Rental Ledger
(Required)
Drop files here or
Select files
Max. file size: 128 MB, Max. files: 1.
Renta Ledger for Arrears
Proof of Damage
(Required)
Drop files here or
Select files
Max. file size: 128 MB, Max. files: 1.
Proof of Payment
(Required)
Drop files here or
Select files
Max. file size: 128 MB, Max. files: 1.
Submit documentation confirming payment for repairs.
Receipts for Materials
(Required)
Drop files here or
Select files
Max. file size: 128 MB, Max. files: 1.
Proof of Repair
(Required)
Drop files here or
Select files
Max. file size: 128 MB, Max. files: 1.
Rental Lease Agreement
(Required)
Drop files here or
Select files
Max. file size: 128 MB, Max. files: 1.
Executed lease agreement between tenant and property.
Move In/Move Out Checklist
(Required)
Drop files here or
Select files
Max. file size: 128 MB, Max. files: 1.
Please provide the Move-In Inspection and Move-Out Checklist.
Notices
(Required)
Drop files here or
Select files
Max. file size: 128 MB, Max. files: 1.
Upload the Notices to cure or quit.
ACKNOWLEDGEMENT
I acknowledge that according to Section 1001 of Title 18 of the United States Code makes it a criminal offense to make willfully a false statement or misrepresentation to any Department or Agency of the Unites States as to any matter within its jurisdiction.
Submitted By
(Required)
First
Last
Point of Contact Email
(Required)
Enter Email
Confirm Email