Brian P. Kemp Christopher Nunn
Governor C
ommissioner
Rev. 3/2019
MUTUAL AGREEMENT FOR TERMINATION OF LEASE
Date:
Owner/Landlord Name:
Tenant Name:
Address of Unit:
By mutual agreement, the above parties agree that the present lease for the rental unit listed above shall be
terminated on the last day of the month of , 20 . Both parties also acknowledge that
the Housing Assistance Payment contract between the Georgia Department of Community Affairs (DCA) and
the Owner/Landlord will also terminate on that date.
The parties further acknowledge that the purpose of this agreement is to verify termination of lease for
purposes of the Housing Choice Voucher program and it does not usurp any either party’s legal rights or
responsibilities regarding their landlord-tenant relationship of either party.
Declaration of Tenant: I am the designated Head of Household and agree with the above statements and will
be moving from the unit on the date stated above. I understand that if I remain in the unit after that date,
DCA will not be responsible for any portion of my rent.
Signature of Tenant (Head of Household) Date
Declaration of Owner/Landlord: I agree with the above statements and further understand that DCA will not
be responsible for any portion of my rent after the date stated above.
Signature of Tenant (Head of Household) Date
Note: This form must be received by the assigned DCA Housing Specialist a minimum of 30 calendar days prior
to the termination date. The Housing Specialist can be identified by searching for “Housing Specialist” on
www.dca.ga.gov or by facsimile to the Norcross Office (770)806-5060 or the Waycross Office (912)285-6367.
