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_____________________________________ _____________________________________ _____________________________________ _____________________________________



I, _______________________________________ (head of household’s name), hereby request an informal settlement hearing to resolve one of the following circumstances: A.

Check one of the following options:

I dispute the amount of rent owed specified in the SFHA communication dated: _______________________________. I deny the actions as defined in the 30-day Notice served to me on: _______________________________________. I want to grieve against an action by the SFHA (please describe): ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ B. State the details of your dispute, denial or grievance: ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ____________________________________________________________ C. State the action you are requesting: _________________________________________________ _________________________________________________________________________________ Head of Household Signature________________________________Date:_____________________ NOTE: You must submit your request for an informal grievance hearing, no more than ten (10) days after the grievable event occurs, to the Property Management Office for the development at which you live or to the Public Housing Operations Department, 1815 Egbert St., San Francisco CA 94124. A COPY OF THE GRIEVANCE POLICY IS AVAILABLE AT ANY PROPERTY MANAGEMENT OR DISTRICT OFFICE. Submission of this request form is the first step in the grievance process. An informal settlement hearing will be held within fifteen (15) days following the receipt of this request. A summary of the discussion at the informal hearing will be sent to you within five (5) days after the hearing is held. If you disagree with the informal hearing decision, you must submit a Request for a Formal Grievance Hearing within ten (10) days of receiving the informal settlement Summary of Discussion. 12/29/2010


Request for Informal Settlement