Memorialization of Rent Payment — Evidence Packet
Prepared by:
[Your name]
· Date:
[Today’s date]
To:
Virginia Department of Housing & Community Development (DHCD)
Housing & Landlord-Tenant Relations Division · 600 E. Main St., Suite 300, Richmond, VA 23219
Packet ID / Case Ref. #
Tenant Contact Email
Tenant (Payer) Name
Tenant Address (Unit)
Landlord / Property
Property Address
Payment Date
Payment Method
Wells Fargo Cashier's Check
Personal Check
Money Order
Online / ACH
Drag & drop check image here
or click Attach Check
Attach Check
Paste Image
Clear Image
Export as PDF (Print)
Download HTML
Check Number
Bank / Issuer
Amount (numeric)
Amount (written)
Received By (office staff)
Delivery Method
Memorialization Narrative / Statement of Facts
On September 5, 2025, the Tenant submitted a Wells Fargo cashier's check in the amount of $1,540.00 to Rose Hall Apartments' leasing office for the rent due for the month of September 2025. This instrument is irrevocable and was timely tendered on the due date. Tenant alleges that on or about July 5, 2025, Rose Hall failed to post the full amount of the rent payment, resulting in multiple inconsistent rent amounts reflected on Rose Hall's account statements/portal. This document, together with the attached cashier's check image (Exhibit A), serves to memorialize the date, instrument, and exact amount paid, and to preserve this information for the administrative record.
Exhibit A — Check Image Filename
Exhibit B — Proof of Payment (bank record)
Relevant Dates
Lease / Unit ID
Requested Agency Action / Notice
[Tenant Name]
Tenant signature (typed name above)
[Signature Date]
Date