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CITY OF BERKELEY
RENT STABILIZATION BOARD
2125 Milvia Street, Berkeley, CA 94704
TEL: (510) 981-7368 TDD: (510) 981-6903 FAX: (510) 981-4910
E-MAIL: rent@ci.berkeley.ca.us INTERNET: www.ci.berkeley.ca.us/rent/

REQUEST FOR MEDIATION

M-_____________

The Rent Stabilization Board offers mediation services to Berkeley landlords and tenants who need help resolving residential tenancy-related matters. Please do not request mediation unless you have first attempted to work the problem out directly with the other person. If you need help deciding whether mediation or the Rent Board's petition process is better suited for your dispute, contact a Rent Board counselor in person or by telephone at the number listed above. Office hours are Mondays, Tuesdays, Thursdays and Fridays, 9:00 a.m. to 4:45 p.m., and Wednesdays, 12:00 p.m. to 6:30 p.m.

Person requesting mediation:

Name _____________________________________ Daytime phone _____________

E-mail _____________________________________

Property Address ____________________________ Unit No. _______ Zip _________

Mailing Address (if different from property address): ____________________________

Availiability of Person Requesting Mediation

I am a:  __tenant  __subtenant  __master tenant  __owner  __property manager

Housing Counselor who assisted you: _____________________________

Person you wish to mediate with:

Name ____________________________________ Daytime phone _______________

E-mail ____________________________________

Address ___________________________ City ___________________ Zip ________

This person is a:  _tenant  _subtenant  _master tenant  _owner  _property manager  _roommate

Brief description of the dispute:
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________

I tried to resolve my dispute directly with the other party, but did not succeed. I give permission to the Rent Stabilization Board to contact the other party to schedule a mediation. I understand that a mediation will be scheduled only if the other party agrees. (Check here if the other party has already agreed to mediation: ___)

Signature_______________________________  Date_______________________