Form E-2 - For Initials+signatures
Form E-2 - For Initials+signatures
Form E-2 - For Initials+signatures
Ver 2.7
Owner Information
First Name: Alexandra
Last Name: Karolinski
Relationship to Property: Owner
Company Name:
Full Mailing Address: 2013 Glencoe Way Los Angeles, CA 90068
Work Phone:
Cell Phone: (646) 388-1125
Home Phone:
Email: alexakarolinski@gmail.com
I declare that I am the owner of the real property described above, and I hereby notify the City of Los Angeles of my
intent to withdraw the rental units indicated on this form from rental housing use. I further declare, under penalty of perjury
under the laws of the State of California, that the information provided on this form and all attached pages is true,
correct, and complete.
All owners must sign. Attach additional pages if necessary.
Print Full Name (Owner 1)
Print Full Name (Owner 2)
Alexandra Karolinski
Signature:
Signature:
Signature:
Date:
Date:
Date:
Address:
Address:
Address:
Recording Date:
Demolition
Converted to:
Used for:
For Office
Use Only:
Non-Rental Housing
Other:
Notice of Intent to
Withdraw Case No.
Amount Paid: $
Demo/Conversion
Clearance Case No.
Amount Paid: $
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Required Documentation
Please call the Landlord Declarations Section at (213) 808-8537 to schedule an appointment for
application submission.
The following documentation is required at the time of application submission:
County Recorded Memorandum Summarizing Non-Confidential Provisions of a Notice of Intent to
Withdraw Units from Rental Housing Use (Form E1)
Notice of Intent to Withdraw Units from Rental Housing Use (Form E2)
Copy of Notice to Tenant of Pending Withdrawal (Form E3) for each occupied unit.
Copy of notice terminating tenancy to be served to tenants, as required by California State Law.
Copy of Grant Deed
Copy of Articles of Incorporation or Articles of Organization, if not owned by a natural person.
For Demolition/Conversion: Copy of LADBS Notice of Intent to Demolish & Clearance Summary
Worksheet.
The following documentation may be submitted after the application has been submission:
Notice of Interest in Renewing Tenancy (Form E4) Copy of Form E4 must be provided to Tenant. If tenant
provides landlord with Form E4, owner must provide HCIDLA with a copy.
Notice to City of Claims for Extended Tenancy (Form E5) If a tenant is entitled to an extended stay of one (1)
year (applies if tenant is at least 62 years of age or is disabled and has lived in the unit for at least one year), the
owner must complete Form E5 and submit it to HCIDLA.
Notice to City of Extended Dates of Withdrawal (Form E6) Landlord may provide the one (1) year extension to
other tenants. Landlord must submit Form E6 to HCIDLA if tenancy extensions are provided.
Notice of Intention to Re-Rent Withdrawn Accommodations (Form E7) If landlord intends to re-rent withdrawn
units, the landlord must submit Form E7 to HCIDLA.
Yes
No
Yes
No
one
*HCIDLA will need to verify that the units are vacant before providing the clearance. Verification may take two to three weeks.
Applicable Fees
0
0
$711 x
$
0
0
$443 x
$
0
0
$ 61 x
$
$ 45 x
$
45.00
1
45.00
Total Amount Due: $
Fees
x No. of Units
Household
Determination
Eligible
Occupancy of
3 Years or More
$10,300
Qualified
$16,500
$19,500
$19,500
$10,300
If the rental unit is occupied by two or more tenants, each tenant shall be paid a pro-rata share. In accordance with LAMC Sec. 151.09.G2, the landlord
shall pay relocation assistance amount owed to the tenant, either directly or via an escrow account in the tenants name, within 15 days of service of a
written notice of tenancy termination.
1 Person
$48,650
2016 HUD Low (80%) Income Household Limits for Greater Los Angeles (AMI)*
2 Person
3 Person
4 Person
5 Person
6 Person
7 Person
$80,600
$86,150
$62,550
$75,050
$69,450
$55,600
Page 2 of 4
8 Person
$91,700
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Home Phone:
Last Name:
Cell Phone:
Email:
Unit has a tenant who is 62 years or older:
Yes
No
Unit has a tenant who is disabled:
Yes
No
Unit has a minor dependent children:
Yes
No
If Yes was marked for any of the three above, the unit is Qualified.
If No was marked for all three, the unit is Eligible.
Date Written Notice of Termination will be Served:
No. of Unit Occupants:
Tenant Information #
First Name:
Work Phone:
Unit Number:
Move In Date:
Current Rent: $
Last Rent Increase Date:
Home Phone:
Last Name:
Cell Phone:
Email:
Unit has a tenant who is 62 years or older:
Yes
No
Unit has a tenant who is disabled:
Yes
No
Unit has a minor dependent children:
Yes
No
If Yes was marked for any of the three above, the unit is Qualified.
If No was marked for all three, the unit is Eligible.
Date Written Notice of Termination will be Served:
No. of Unit Occupants:
Tenant Information #
First Name:
Work Phone:
Unit Number:
Move In Date:
Current Rent: $
Last Rent Increase Date:
Home Phone:
Last Name:
Cell Phone:
Email:
Unit has a tenant who is 62 years or older:
Yes
No
Unit has a tenant who is disabled:
Yes
No
Unit has a minor dependent children:
Yes
No
If Yes was marked for any of the three above, the unit is Qualified.
If No was marked for all three, the unit is Eligible.
Date Written Notice of Termination will be Served:
No. of Unit Occupants:
Tenant Information #
First Name:
Work Phone:
Unit Number:
Move In Date:
Current Rent: $
Last Rent Increase Date:
Home Phone:
Last Name:
Cell Phone:
Email:
Unit has a tenant who is 62 years or older:
Yes
No
Unit has a tenant who is disabled:
Yes
No
Unit has a minor dependent children:
Yes
No
If Yes was marked for any of the three above, the unit is Qualified.
If No was marked for all three, the unit is Eligible.
Date Written Notice of Termination will be Served:
No. of Unit Occupants:
Notice of Intent to Withdraw Units from Rental Housing Use
Form E2
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Fees paid to the Los Angeles Housing + Community Investment Department (HCIDLA) are nonrefundable, therefore it is your obligation to be aware of the Rent Stabilization Ordinances Ellis
Act Provisions before submitting fees.
Owner Certification
I hereby declare, under penalty of perjury under the laws of the State of California, that the information
provided in this form is true and correct to the best of my knowledge and belief and that I am evicting the
tenant(s) at the rental property identified on this form in order to remove the rental units from rental housing
use.
I acknowledge that I will be responsible for providing monetary relocation assistance to the tenant(s) being
evicted in accordance with LAMC 151.09.G. If the City determines that a higher Relocation Assistance
Services Provider Fee is due based on a different relocation eligibility status determination, I will compensate
the City for the balance due. All fees are non-refundable. I further acknowledge that if I re-rent the withdrawn
accommodations, the rent for any subsequent tenant(s) is not decontrolled and therefore, must be
established at the rental amount of the current tenant plus any increases allowed by LAMC 151.06C.
Owners Signature:
Date:
Any person who willfully or knowingly with the intent to deceive makes a false statement or representation, or knowingly
fails to disclose a material fact in this form shall be guilty of a misdemeanor (LAMC 151.10B).
Acknowledgement
I acknowledge that I have received the Procedures for Withdrawing Rental Units from the Rental
Market packet.
Initials:
Schedule an Appointment
Call (213) 808-8537 to schedule an appointment for application submission.
Appointment Date and Time:
Assigned Analyst:
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