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DC-4104

Affidavit of Tenant in Response to Landlord’s Notice of Nonpayment

Virginia · Supreme Court of Virginia

This form is an affidavit that a tenant fills out to respond to a notice from a landlord about not paying rent. The tenant uses it to state that they have made all required payments, and that the landlord has not properly recorded those payments.

Open the official PDFfrom Supreme Court of Virginia

Where this fits in a case

Respond

Stage: Respond

This form is used in the context of an eviction case, specifically within the General District Court Eviction Diversion Program, when a tenant needs to respond to a Landlord's Notice of Nonpayment.

Usually filed by the person responding.

Common questions

Who fills out this form?
The undersigned defendant/tenant fills out this form. You must sign it under oath.
What does this form help prove?
It allows the tenant to state that they have made all payments required by a court-ordered plan or rental agreement, and that the landlord has not properly acknowledged those payments.

Revision history

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

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