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DC-4101

Request for Referral

Virginia · Supreme Court of Virginia

This form is a request from the tenant to the court asking to be sent to the Eviction Diversion Program. The tenant must state under oath that they can pay a certain amount on the hearing date and provide details about their inability to pay rent.

Open the official PDFfrom Supreme Court of Virginia

Where this fits in a case

Motions

Stage: Motions

This form is used by the tenant in an eviction case to ask the court to refer the case to the Eviction Diversion Program.

Usually filed by the person responding.

Common questions

Who fills out this form?
The defendant/tenant fills out this form. This form is for the tenant to submit to the court.
What must the tenant state about payments?
The tenant must state if they can pay at least 10% of the amount due on the hearing date. They must also answer questions about their income and payment plans.
Is a fee involved?
The form asks the tenant to state how much money they will pay on the hearing date.

Revision history

No changes recorded since we started tracking this form on October 10, 2026.

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