Dispute Resolution

Rental Housing Dispute Resolution
Office of the District Attorney
Consumer Protection Division
3501 Civic Center Drive, Room 145
San Rafael, CA 94903 (415) 473-6495
Who should fill this form?

Tenant who has received notice of a rent increase of more than 5% in a 12-month period.

Landlord who intends to increase my tenant's rent by more than 5% in a 12 month period.
Request Type*

TenantLandlord
Tenant Information
Rental Physical Address
Address*
City*
State*
Zip Code*
Tenant's Contact Information
Tenant First Name*
Tenant Middle Name
Tenant Last Name*
Tenant's Mailing Address
Check if applicable:

Mailing Address same as Rental Physical Address
Address
City
State
Zip Code
Check if applicable:

Email address is unknown
Email Address*
example@example.com
Phone*
Phone Number
Check if applicable:

Are you over the age of 62?
Tenant Representative's Contact Information
If a tenant is unable to participate in mediation, they may designate a representative to negotiate on their behalf.
Check if applicable:

I designate a representative to negotiate on my behalf
Name*
Mailing Address*
Email Address*
example@example.com
. Phone*
Phone Number
Landlord Information
Dispute with*

PersonCompany
Landlord Company*
Landlord First Name*
Landlord Middle Name
Landlord Last Name*
Landlord's Mailing Address
Address
City
State
Zip Code
Email Address
example@example.com
Phone
Format: (999) 999-9999
Check if applicable

Are you over the age of 62?
Landlord Representative's Contact Information
If a landlord is unable to participate in mediation, they may designate a representative to negotiate on their behalf
Check if Applicable

I designate a representative to negotiate on my behalf
Name*
Mailing Address*
Email Address*
example@example.com
Phone*
Format: (999) 999-9999
General Rental History
Move In Date*

MonthDayYear
Initial Monthly Rent*
Current Date*

MonthDayYear
Current Monthly Rent*
New Rent Amount*
New Rent Effective Date*

MonthDayYear
Are the rent payments current?*

YesNo
If "no." please explain (e.g. "rent has not been paid this month," or "rent has not been paid for 3 months," etc. and provide rationale.) If rent is being withheld due to alleged habitability violations. please identify those conditions here.
Have you previously participated in mediation for this rental unit or with this landlord/tenant?

YesNo
Date of Mediation 1*

MonthDayYear
Outcome of Mediation 1*
Date of Mediation 2

MonthDayYear
Outcome of Mediation 2
Date of Mediation 3

MonthDayYear
Outcome of Mediation 3
Estimated Number Of Homes On Property*
Are you a part of a larger group seeking mediation?*

YesNo
Please list any other requests for mediation that you think should be heard concurrently with this request.
Attachments
Please attach all supporting documents (receipts, contracts, correspondence). File types of .pdf, .jpg, .jpeg,. png, .doc, .docx, .xls, .xlsx are accepted. If your attachment is larger than 20MB, you'll have the opportunity to forward it at a later time when you are contacted by District Attorney staff.
Attachment Upload

.pdf, .jpg, .jpeg, .png, .doc, .docx, .xls, .xlsx - 20MB or less
Cancelof
Sign and Submit
Check to confirm and sign*

By checking this box I attest that the information provided in this form is true.
Confirmation*
Internal Fields
Assign To
Category Id
Complaint Summary
Action*

Send to DarwinDo not move to Darwin
Staff Email
example@example.com
Submitter Email
example@example.com
Reply Email
Submission Date & Time*

MonthDayYear
Hour MinutesAM/PM Option
Tenant Over 62
Landlord Over 62
Submission Date & Time (Original PDF)
Move In Date (Original PDF)

MonthDayYear
Date
Current Date (Original PDF)

MonthDayYear
Date
New Rent Effective Date (Original PDF)

MonthDayYear
Date
Date of Mediation 1 (Original PDF)

MonthDayYear
Date
Date of Mediation 2 (Original PDF)

MonthDayYear
Date
Date of Mediation 3 (Original PDF)

MonthDayYear
Date
Respondent (Onbase Integration)
Submission Status
Should be Empty:

Rental Housing Dispute Resolution

Who should fill this form?

Tenant Information

Rental Physical Address

Tenant's Contact Information

Tenant's Mailing Address

Tenant Representative's Contact Information

Landlord Information

Landlord's Mailing Address

Landlord Representative's Contact Information

General Rental History

Attachments

Sign and Submit

Internal Fields