The following statements and question in bold letters with a space for the tenant
to affix their initials next to each possible answer:
"Owners who fail to comply with the requirements of Oakland's Tenant Move Out Agreement
Ordinance (O.M.C. 8.22.700, et seq.) may be subject to more significant penalties if the tenant is elderly,
disabled, or catastrophically ill. As defined in the Ordinance, elderly tenants are
sixty (60) years of age or older. Tenants are disabled if they are disabled under
Section 12926 of the California Government Code. Tenants are catastrophically ill
if they are both disabled under Section 12926 of the California Government Code and
suffering from a life-threatening illness, as certified by their primary care physician.
Do you believe that you are elderly, disabled, or catastrophically ill as those terms
are defined above? Yes ___ No ___ I don't know ___ I prefer not to say ___."
15.
A space for the owner to sign and write the date on which the owner provided the tenant
with the disclosure form; and
16.
A space for each tenant to sign and write the date on which they received the disclosure
form.
B.
The owner shall provide the tenant with a fully executed copy of the disclosure form,
or a copy of the disclosure form executed by the owner, within three (3) days of execution.
C.
The owner shall retain at least one (1) copy of each executed disclosure form, or
the disclosure form executed by the owner along with a proof of service to the tenant,
for five (5) years after the date on which the tenant executes the form or the owner
serves the form. the owner shall maintain a record of the date(s) on which the owner
provided the disclosure form to each tenant.
D.