Landlord Mitigation Reimbursement Claim Submission Form

Please do not use autofill on this form as this creates input errors.

This form is required for each claim related to reimbursement for repairs to a rental unit to pass a rental subsidy program inspection and for claims against tenant damages. All required sections and attachments must be completely filled in accurately/ attached to be submitted.

Only submit one claim per tenant. Additional attachments may be sent to

Do not close the application page until you receive a confirmation email.

You are required to have a SWV number to enter a claim. If you do not have one, complete the form and follow the instructions found by visiting this site:

Please be sure to enter the extension (-00) as these can vary per property.

This is to ensure your payment is processed properly. Please verify both SWV boxes match.

Include the street number and name, city, state and zipcode

Leave blank if there is not property name.

Include the street number and name, city, state and zipcode

If multiple tenants, list the primary subsidized tenant.

If no address is known use the property street address.

If no address is known use the property city, state and zip code.

Enter the total value of the claim that you are submitting. (Maximum claim amount is $5,000)

Please include any additional information that will be helpful in evaluating your claim.

Each of the following must be attached one at a time. File size not to exceed 30mb per attachment and no more that 10 total attachments (combine documents and photos if possible).

> Proof of subsidy
> Subsidy inspection report
> Executed original term rental agreement
> A completed move-in condition report signed by landlord and tenant
> Tenant ledger showing unpaid rents and collection of the security deposit
> Notices sent to tenant for unpaid balances being claimed.
> Copies of all repair invoices/receipts included in this claim.
> Before and after photos of damages with description that are included on this claim (if able).

Only submit one claim per tenant. Attach documents first. If more information or photos are required, they will be requested by Commerce.

Verify each attachment below.

Submitter's Certificate: The individual signing this voucher below warrants they have the authority to do so as authorized and on behalf of the entity identified in the Owner section above. The individual signing below certifies under penalty of perjury that the information, attachments and totals listed herein are true, honest and proper charges for remedy required for damages caused by the tenant(s) listed on this application.

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